HomeMy WebLinkAbout03-0330PETITION FOR PROBATE and GRANT OF LETTERS
Estate of Albert Rabena No. 21-03-330'
also known as To:
· Deceased.
Social Security No. 172-01-0352
gegister of W rr? nd
County of
Commonwealth of Pennsylvania
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/.m~ 18 years of age or older an the execut rix
in the last will of the above decedent, dated cu-,er, bar 1
and codicil(s) dated
in the
named
,19 97
(state relevant circumstances, e.g. renunciation, death of executor, etc.)
Decendent was domiciled at death in Cumberland Cn,,nrv
h is last family or principal residence at ..402 Vi~tzcn~
' - (list street, number and muncipality~
Decendent, then ~. 5ears of age, died ~ch 8r 2003 , ~ ,
at ~oal~h ~n~h: R~nova ~.~ Up~r All~ ~shiD
Except as follows, decedent did not marry, was not ~ivorced and did not have a child born or adopted
after execution of the will offered for probate; was not the victim of a killing and was never adjudicated
incompetent:
Decendent at death owned property with estimated values as follows:
(I f domiciled in Pa.) All personal property
(If not domiciled in Pa.) Personal property in Pennsylvania
(}f not domiciled in Pa.) Personal property in County
Value of real estate itl Pennsylvania
situated as follows:
$ 175,000.00
WHEREFORE, petitioner(~ respectfully
presented herewith and the grant of letters
theron.
request(s) the probate of the last will and codicil(s)
(testamentary: administration ¢.t.a.: administration d.b.n.c.t.a.)
~CCl~eline M. B8'11--
//110 ~;unrise Avenue
New Cumberlan0, PA 17070
OATH OF PERSONAL REPRESENTATIVE
COMMONVfEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
The petitJor,.er~s) above47amed 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-
taupe(s) o{ tile above d~.cedent euqoner s will and trul
".' ' ~ P '-' ( ) ' ~ y administer the estate ~cordi~g to law.
before me this 14th day of I /7~ ' I~'
No. 21-03-330
Estate of ~L~RT ~m , Deceased
DECREE OF PROBATE AND GRANT OF LETTERS
~ND NOW APRIL 15 ~ , in consideration of the petition on
the reverse side hereof, satisfactory proof having been presented before me,
IT IS DECREED that the instrument(s) dated October 1, 1997
described therein be admitted to probate and filed of record as the last will of A1 h~r~- g~n~
and Letters ~
are hereby granted to Jacqueline ..M Ball
FEES
Probate, Letters, Etc .......... $ 235.00
Short Certificates( ) .......... $ 12.00
18.00
~-ep ag e.s.
nunaauon ................ $
JCP $ 10. O0
TOTAL .
Filed APRIL 15, 20.0.~
Barbara Sumple-Sullivan, Esquire
Supreme Court I.D.: 32317
ATTORNEY (Sup. Cl. I.D. No.) ._.
549 Bridge Street, New Cumberland, PA 17070
ADDRESS
(717) 774-1445
PHONE
his is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as
l,ocal Registrar. The original certificate will be forwarded to thc State Vital Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Feep S0930gTfor this certificate, $2.00
No.
Local Registrar
COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS
CERTIFICATE OF DEATH
U~R ~Y~ UNDER D~ - . ~' _
,~. Cumberland ~ Upper Allen ~p. ~Health South, Renova Ctr. ~.~"~V~' ~ white
,,. New Cumberland, PA 17070 ~) ,~.c~.~ Cumberland ~"~'"? ,~.~~ New Cumberland
,~. Anthony Rabena ,,. Bella Valenza
~. Jacqueline M. Ball ~. 110 Sunrise Avenue~ New Cumberland~ PA 17070
~.,~ ~(s~ ~,,~rch 12, 2003 ~lling Green Memorial Parkl,,~ower Allen ~p., PA 17011
~,- %~~~~~,,u. FS 012 849 L ~=~.P.O. Box 431, New Cumberland,PA 17070-0431
~A~ ~D A~E~ ~ ~RSON WH~ ~M~ED C~ ~
LAST WILL ~VD TEST~IENT
OF
~LBERT RABENA
I, ALBERT RABENA, of 402 West 15th Street, New Cumberland,
Cumberland County, Pennsylvania, do make, publish and declare this to be my Last
Will and Testament, hereby revoking all Wills and Codicils by me at any time made.
ITEM I: I direct that all inheritance and estate taxes becoming due by t:eason
of my death, whether such taxes may be payable by my estate or by any recipient of any
property, shall be paid by the Executor out of the property passing under ITEM IV of
this Will, as an expense and cost of administration of my estate. The Executor shall
have no duty or obligation to obtain reimbursement for any such tax so paid, even
though on proceeds of insurance or other property not passing under this Will.
ITEM II: I direct the Executor to pay my just debts and the expenses of my
last illness and funeral expenses from the property passing under this Will as an
expense and cost of administration of my estate.
1
ITEM III: A) In the event my spouse has predeceased me, I make the following
specific bequest:
(1) I devise and bequest the sum of ONE THOUSAND DOLLARS
($1,000) to my grandson, DAVID A. BALL, In the event said child is less than
20 years of age, said sum shall be given to the child's legal guardian and used
for the benefit of the child as the legal guardian, in his or her sole discretion,
determines to be appropriate.
(2) I devise and bequest the sum of ONE THOUSAND DOLLARS
($1,000) to my grandson, NElL D. BALL. In the event said child is less than
20 years of age, said sum shall be given to the child's legal guardian and used
for the benefit of the child as the legal guardian, in his or her sole discretion,
determines to be appropriate.
B) At the time of my dealth, I devise and bequest the sum of ONE
THOUSAND DOLLARS ($1,000) to the NEW CUMBE~ FIREMAN'S
AMERICAN LaFRANC (23) TRUCK FUND.
II'EM IV:
bequeath to'my wife, FLORENCE A. RABENA.
All the rest, residue and remainder of my estate I devise and
In the event my wife predeceaSes me
or, in the event she does not survive me by thirty (30) days, · devise and bequeath my
estate as follows:
(a) One-half (1/2) to my son, RONALi) A. RABENA, or in the:event
he predeceases me, to his issue, per stirpes.
(b) One-half (1/2) to my daughter, JACQUELINE MAY BALL, or in
the event she predeceases me, to her issue, per stirpes.
In the event any beneficiary above predeceases me, his or her share shall be paid
to the other named survivor referenced above.
ITEM V: In the settlement of my estate, my Executor shall possess, among
others, the following powers: ,
(a) To retain any investments · may have at my death, as long as the
Executor may deem it advisable to my estate to do so;
~b) To sell either at private or public sale and upon such terms and
conditions as the Executor may deem advantageous to the estate, any or all real
or personal property or interest therein owned by the estate;
(c) To pay all costs, taxes, expenses and charges in connection with the
administration of my estate;
(d) To compromise controversies; and
(e) To do all other acts in the Executor's judgment deemed necessary
or desirable for the proper and advantageous management, investment and
distribution of the estate.
ITEM VI: Any person who shall have died at the same time as I shall have,
or in a common disaster with me, or under circumstance that the order of deaths
cannot be established by proof, or within thirty (30) days of my death, shall be deemed
to have predeceased me.
ITEM VII: I appoint my wife, FLORENCE A. RABENA, to be the Executrix
of my Estate. In the event my wife cannot act or refuses to act as Executrix for any
reason, I nominate, constitute and appoint my daughter, JA CQUELINE M. BALL, as
alternate Executrix.
Any Executrix is specifically relieved from the duty or obligation
o f filing any bond or other security.
IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my
Last Will and Testament, consisting of this and the preceding 3 pages, at the end of
each page of which
identification this
I have also set my initials for greater security and better
~day of ~F~% 1997.
ALBERT RABENA
4
We, the undersigned, hereby certify that the foregoing Will was signed, sealed,
published and declared by the above-named Testator as and for his Last Will and
Testament, in the presence of each other, have hereunto set our hands and seals the
day and year first above written, and we certify that at the time of the execution
thereof, the said Testator was of sound mind and memory.
Lisa Zi~z'~
Residing at: 205 A Tenth Street
New Cumberland, PA
Michael T. Stephens
Residing at: 313D Eden Road
Lancaster, PA 17601
A CKNO WLED~E]~IENT
COMMONWEALTH OF PENNSYLVANIA :
: SS.
COUNTY OF CUMBERLAND :
I, ALBERT RABENA, Testator, whose name is signed to the attached or
foregoing instrument, having been duly qualified according to law, do hereby
acknowledge that I signed and executed the instrument as my Last Will and Testament;
that I signed it willingly, and that I signed it as my free and voluntary act for the
purposes therein expressed.
(SEAL)
ALBERT RABENA
Sworn to and subscribed
befor~e/~.e this //,~ day
of ~(~//~/~-~, 1997.
//NOTARY PUBLIC
My Commission Expires:
(SEAL)
NOTARIAL SEAL
Bafoara Sumple-Sultivan, Notary Public
New Cumberland Boro, Cumberland Co.
My Commission Exptres Nov. 15, 1999
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA :
: SS.
COUNTY OF CUMBERLAND :
We, Lisa Zizis, and Michael T. Stephens, the witnesses whose names are signed
to the attached or foregoing instrument, being duly qualified according to law, do
depose and say that we were present and saw Testator, ALBERT RABENA, sign and
execute the instrument as his Last Will and Testament; that Testator signed willingly
and he executed said Will as his free and voluntary act for the purposes therein
expressed; that each of us in the hearing and sight of the Testator signed the Will as
witnesses; and that to the best of our knowledge the Testator was at that time eighteen
(18) or more years of age, of sound mind and under no constraint or undue influence.
Lisa Zips ~/
Sworn to and subscribed
bef o~/~ne/this (~ /- day
My Commission Expires: (SEAL)
Michael T. Stephehs
ani~
ALBERT RABENA
LAW OFFICES
BARBARA SUMPLE-SULLIVAN
549 BRIDGE STREET
NEW CUMBERLAND, PENNSYLVANIA 17070-1931
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 002654
SUMPLE-SULLIVAN BARBARA
549 BRIDGE STREET
NEW CUMBERLAND, PA 17070
........ fold
ESTATE INFORMATION: SSN: 172-01-0352
FILE NUMBER: 2103-0330
DECEDENT NAME: RABENA ALBERT
DATE OF PAYMENT: 06/06/2003
POSTMARK DATE: 06/05/2003
COUNTY: CUMBERLAND
DATE OF DEATH: 03/08/2003
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 $7,500.00
TOTAL AMOUNT PAID.
$7,500.00
REMARKS: JACQUELINE Q BALL
C/O BARBARA SUMPLE-SULLIVAN
SEAL
CHECK# 313
INITIALS: AC
RECEIVED BY:
DONNA M. OTTO
DEPUTY REGISTER OF WILLS
REGISTER OF WILLS
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
BEFORE THE REGISTER OF WILLS, CUMBERLAND COUNTY, PENNSYLVANIA
Name of decedent: Albert Rabena
Date of death: March 8, 2003
No. 21-03-0330
To the Register:
I certify that notice of beneficial interest required by Rule 5.6(a) of the Orphan's Court
Rules was served on or mailed to the following beneficiaries of the above-captioned estate as
follows:
Name: Address: Dated Mailed
New Cumberland Fireman's
American LaFranc (23) Truck Fund
1319 Fourth Street
New Cumberland, PA 17070
May19,2003
Mr. Ronald A. Rabena
P.O. Box 186
Calvin, PA 16622
June 5, 2003
Mr. Neil D. Ball
110 Sunrise Avenue
New Cumberland, PA 17070
June 5, 2003
Mr. David A. Ball
9828 EmoryRoad
Box 3236
Fo~Meade, MD 20755
June 5, 2003
Ms. Jacqueline M. Ball 110 Sunrise Avenue June 5, 2003
New Cumberland, PA 17070
Notice has now been given to all persons entitled th~
Date: June.~_, 2003
(~p~e-~umvan, e, sqmre 549 Bridge Street
New Cumberland, PA 17070
(717) 774-1445
Supreme CT. ID # 32317
Capacity: __
X
Personal Representative
__ Counsel for Personal
Representative
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 00331 5
SUMPLE-SULLIVAN BARBARA
549 BRIDGE STREET
NEW CUMBERLAND, PA 17070
fold
ESTATE INFORMATION: SSN: 172-01-0352
FILE NUMBER: 2103-0330
DECEDENT NAME: RABENA ALBERT
DATE OF PAYMENT: 12/08/2003
POSTMARK DATE: 1 2/05/2003
COUNTY: CUM BERLAN D
DATE OF DEATH: 03/08/2003
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 $768.06
TOTAL AMOUNT PAID:
9768.06
REMARKS: RECEIVEDJACUELINEA BALL
IN CO BARBARA SUMPLE SULLIVAN
SEAL
CHECK#323
INITIALS: AC
RECEIVED BY:
DONNA M. OTTO
DEPUTY REGISTER OF WILLS
REGISTER OF WILLS
J. COMMONVVEALTH OF
PENNSLYVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
RABENA, ALBERT
DATE OF DEATH (MMIDD-YEAR) I DATE
OF
BIRTH
(MM-DD-YEAR)
March 8, 2003 mi January 26, 1917
IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
OFFICIAL USE ONLY
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
21 . 03
COUNTY CODE YEAR
SOCIAL SECURITY NUMBER
172-01-0352
0330
NUMBER
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
1. Original Return ~ 2. Supplemental Return ~J 3. Remainder
4. Limited Estate I 14a. Future Interest Comprise (date of death after 12-12o82)
5.
Federal
Estate
Tax
Return
Required
6. Decedent Died Testate (Attach copy of Will) J Jr-'-I 7. Decedent Maintained a Living Trust (~tach, copy or Trust) I___1 8. Total Number
of
Safe
Deposit
Boxes
9. Litigation Proceeds Received ~b~ 10. spousal Poverty Credit (date of death between 12-31-91 and 1-1-95} ~'~ 11. Election to tax under Sec. 9113 A
-- I I (Attach Sch O) (
THIS SECTION MUST BE COMPLE,t:D. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
NAME
Barbara Sumple-Sullivan, Esquire
FIRM NAME (If Applicable)
TELEPHONE NUMBER
(717) 774-1445
COMPLETE MAILING ADDRESS
Bridge Street
New Cumberland, PA 17070
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 &Misc. Personal Property (Schedule E) (5)
6. Jointly Owned Property (Schedule F) (6)
[ ~'~] Separate Billing Requested
7, Inter-Vivos Transfers & Misc. Non-Probate Property (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
10. DeMs of Decedent, Mortgage Liabilities & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
(8)
$ 0.00
$151,979.50
$ 0.001
$23,437.50
$6,295.75
$26,212.82
$ 0,00 i
OFFICIAL USE ONLY
(11)
(12)
$10,692.58
$4,164.82
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been (13)
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13) (14)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RJtTES
$207,925.57
$14,857.40
$193,068.17
$1,000.00
$192,068.17
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
x (15)
16. Amount of Line 14 taxable at lineal rate $192,068.17
x .045 (16)
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)
20. r'~ CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
$ 0.00
$8,643.06
$ 0.00
$ 0.00
$8,643.06
> · BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < <
Decedent's Complete Address
Ss 402 fifteenth Street
STATE
PA
ZIP
17070
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
Interest/Penalty if applicable
D. Interest
E. Penalty
7500.00
375.00
Total Credits (A + B + C) (2)
Total Interest/Penalty (D + E)
If line 2 is greater than line 1 + line 3, enter the difference. This is the OVERPAYMENT
Check box on Page 1 Line 20 to request a refund
If line 1 + line 3 is greater than line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE
(3)
(4)
(5)
(5A)
(5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
$8,643.0~
$7,875.00.
$ 0.00
$ 0.00
$768.06
$768.06
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes
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 revisionary 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 on 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?
No
IF THE ANSWER TO ANY OF THE ABOVE QUESTK)I~ IS YES, YOU MUST COMPLETE SCHEDULE G AND RLE 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.
Declarafi~"~eparer other than the personal representative is bas~ed on all the informatJo~ of which preparer has any I~nowledge.
SIGN/~D~,~~UR PE SO ESP(3NSIBI~
ADI~ESS
549 Bride Street, New Cumberland, PA 17070
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 Jahuary 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 n common with the decedent, whether by blood or adoption.
REV-1503EX + (1-97) (I)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
ESTATE OF RABENA, ALBERT FILE NUMBER 21-03-0330
All property jointly.-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DA'
NUMBER DESCRIPTION OF DEATH
1. Prudential Securities, Account No. 044-334747-023 $151,97!
TOTAL (Also enter on line 2, Recapitulation)
$151,97.c
(If more space is needed, insert additional sheets of the same size)
Prudential Financial
Prudential Securities Incorporated
3 Lemoyne Drive
Lemoyne, PA 17403
PO Box 7, Camp Hill, PA 17001-9852
Tel 717 761-7344 800 466-8685
Fax 717 975-8426
March 25, 2003
Mrs. Jacqueline R. Ball, Executrix
The Estate of Albert Rabena
70 Sunrise Avenue
New Cumberland, PA 17070-3053
Estate of Albert Rabena
Prudential Securities Account No. 044-334747-023
SS# 172-01-0352
Date &Death: March 8, 2003
Dear Mrs. Ball:
Enclosed please find the date of death values for the above account. Since your father died on a Saturday,
I have enclosed the values for both Friday, March 7th and Monday, March 10t~. The accrued interest for
the fixed income investments (certificates of deposit and corporate bonds) is also included and itemized.
We will require a federal identification number and short certificate for the estate account here at
Prudential Securities Incorporated. I have enclosed a stamped self-addressed envelope for mailing that
information to our office.
If you have any questions regarding any of the securities in your father's account, please do not hesitate to
contact me.
Sincerely,
Bruce D. Mulvey
Associate Vice President Investments
Cc: Barbara Sumple-Sullivan, Esq.
Page 2
Estate of Albert Rabena
Prudential Securities Account No. 044-334747-023
Date of Death: March 8, 2003
Value Value
Amount Security 03/07/2003 03/10/2003
10,000 Ford Motor Credit Company $ 9,865.30 $ 9,867.75
4.60% 05/20/2004 21.42 25.20
10,000 General Motors Acceptance Corp 10,052.40 10,071.10
4.25% 07/15/2004 60.32 63.80
10,000 General Motors Acceptance Corp 10,117.00 10,131.90
7.625% 11/15/2012 234.08 240.35
640.980 Lord Abbett Affiliated Fund uA" 6,255.96
6,095.72
120.024 Capital Income Builder Fund "A" 4,778.16
4,734.95
10,000 CD+ Builders Bank 9,951.90 9,969.30
1.80% 01/29/2004 18.62 20.09
10,000 CD+ Beal Bank 10,005.48 10,005.35
2.15% 04/23/2003 131.57 133.34
I0,000 CD+ Blue Bonnet Savings Bank 10,012.35 10,012.15
2.40% 05/14/2003 172.92 174.90
10,000 CD+ BMW Bank 10,041.30 10,054.61
2.75% 11/17/2003 196.50 198.75
10,000 CD+ National Republic Bank 9,983.65 9,983.69
2.20% 04/26/2004 79.20 81.00
10,000 CD+ Mill Creek Bank 9,999.98 9,999.87
1.80% 02/26/2004 5.39 6.86
49,984 Prudential Moneymart Assets Fund 49,984.00 49,984.00
12.00 15.00
***TOTAL*** ..............
$151,979.50 $151,869.68
"This representation of your account is not the official record of your account. It is for informational
purposes only and has been prepared to assist you with your investment planning. Your Prudential
Securities Client Statement is the official record of your account. Therefore, if there are any discrepancies
between this information and your Client Statement, you should rely on the Client Statement and call your
local Branch Manager with any questions."
REV-1507 EX + (1-97)(1)
COMMON~VEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE D
MORTGAGES & NOTES
RECEIVABLE
ESTATE OF RABENA, ALBERT FILE NUMBER 21-03~0330
All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1.
Decedent held 250 shares of Bardcom, Inc., a private corporation. On or about January 24, 2002,
Bardcom, Inc. entered into an Asset Purchase Agreement with Megahertz Radio, LLC and
Megahertz Licenses, LLC to transfer its entire holdings (Attached are pertinent paragraphs regarding
)rice). At the time of death, Decedent had the following due to him:
6.25% of $275,000.00
6.25% of $100,000.00
Residual value of stock $0.00
$17,187.50
$ 6,250.00
TOTAL (Also enter on line 4, Recapitulation) $23,437.50
(If more space is needed, insert additional sheets of the same size)
Andrew M. Hunter SEC'.E~^,y --
BARDCOM, INC.
INCORPORATED UNDER THE LAWS OF THE COMMONWEALTH OF PENNSYLVANIA
Authorized Shares 100,000 Par Value $]. Per Share
ALBERT RABENA and FLORENCE RABENA, his
~hi~r~ifif~ ~h~ wife, as tenants by the entiret'es ·
................ TWO HUNDRED FIFTY .....
BARDCOM, INC. ~ ~/~/
nald A. Rabena ~--R~S,DE~~
The sale, transfer, pledge, assiqnmen~, encumbrance or other disposition
of this certificate and the shares of stock represented by this certifi-
cate is subject to a Shareholders Agreement dated , 1987, a Copy
of which is on file with the Secretary of the corporation.
The following abbrev ations, When Used in the inscription on the face of this cert ficate shall be c
to applicable laws o_r regulations.: , onstrued as though they were written out in full according
TEN COM as tenants in common UNIF GIFT/WIN ACT
TEN ENT --as tenants by the entireties · · ((~. · Custodian .......... under
JT TEN --as joint tenants with right of survivorship Uniform Gifts to Minors(~? .............
and not as tenants in common
Additional abbreviations may also be used though not in the above list. (State)
,~, ',~
2ND DRAFT
JANUARy 21, 2002
ASSET PURCHASE AGREEMENT
Between
BARDCOM, INC.
as Seller
and
MEGAHERTZ RADIO, LLC
and
MEGAHERTZ LICENSES, LLC
as Buyers
Dated: JANUARy ~_~, 2002
TABLE OF CONTENTS
Section
2.
3.
4.
5.
6.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
Definitions
Assets to be Conveyed ........
Excluded Assets\Accounts Receivable Collections ....
Purchase Price and Method of Payment .
Prorations ......
Representations and Warranties of
Seller
Affirmative Covenants of Seller
........... 18
Negative Covenants of Seller
............ 19
Representations and Warranties of
Buyers ............
........... 20
Environmental Site Assessment
............ 21
Conditions Precedent to Buyers,
Obligations ....
.......... 25
Conditions Precedent to Seller,s
Obligations
......... 28
Application for Commission Consent and
Approval ....
Control of the Stations ....
Termination
Risk of Loss .....
Indemnification
Expenses/Taxes ..........
Seller,s Performance at Closing .....
Buyers, Performance at Closing ...........
Survival of Representations
and Warranties ...........
......... 39
2
3
4
6
8
29
30
30
32
33
36 ,,
37
38
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
Other Governmental Consents . .
.......... 39
Cure
................ 39
Finders, Consultants and Brokers
.......... 40
Notices . . .
...... 40
Successors and Assigns ........
....... 41
Announcements/Press Releases ......
...... 41
Other Documents .............
...... 42
Exhibits and Schedules
............... 42
Construction .................... 42
Counterparts ............
........ 42
Headings
...... 42
Entire Agreement
.................. 42
EXHIBITS:
Exhibit "A":
Exhibit "B":
Exhibit "C":
Exhibit "D":
Exhibit "E":
Exhibit "F":
Exhibit "G":
Exhibit "H":
Exhibit "I":
Exhibit ,,j,,:
Exhibit "K":
Exhibit "L":
Exhibit "M":
Licenses
Tangible Personal Property
Real Property
Assumed Contracts
Intangible Personal Property
Noncompetition Agreement
Escrow Agreement
Form of Promissory Note
Third Party Consents
Opinion Letter - Seller,s Counsel
Intentionally Omitted
Seller's Resolution
Seller's Closing Certificate
2ND DRAFT
JANUARY 21, 2002
ASSET PURCHASE AGREEMENT
This Asset Purchase Agreement, made and entered into this
~ day of January, 2002, by and between BARDCOM, INC. ("Seller"),
MEGAHERTZ RADIO, LLC ("Radio, LLC") and MEGAHERTZ LICENSES, LLC
("Licenses, LLC"), and sometimes hereinafter referred to
collectively with Radio, LLC as "Buyers", and Seller and Buyers are
sometimes hereinafter collectively referred to as the "Parties" or
singly as "Party") .
W I TNE SETH:
WHEREAS, Seller is the licensee of, and owns and
operates, radio broadcast stations WHUN(AM) and WXMJ(FM), licensed
respectively to Huntingdon, Pennsylvania and Mt. Union,
Pennsylvania ("Stations"); and
WHEREAS, Buyers desire to purchase and Seller desires to
sell to Buyers substantially all of the tangible and intangible
personal property (excluding accounts reCeivable) and real property
used and useful in the operation of the Stations, including the
assignment of certain contracts, leases and agreements of Seller
and the Stations, and also the'licenses and other authorizations
issued by the Federal Communications Commission (the
"Commission") for the operation of the Stations
Licenses");
covenants
"FCC" or
(the "FCC '
NOW, THEREFORE, for and in consideration of the mutual.
and agreements between the Parties hereto herein
pay), but Seller shall provide Radio, LLC with prompt notice of any
such payment. Every thirty (30) days during the Collection Period,
Radio, LLC shall make a payment to Seller equal to the amount of
all collections of Seller Accounts Receivable during such thirty
(30) day period less any commissions and/or other expenses due
thereon (which Radio, LLC is hereby directed to pay on Sellers
behalf); provided, however, that no commissions shall be deducted
from Seller Accounts Receivable and paid to former employees or
local sales agents of Seller without Seller's prior approval. At
the end of the-120-day collection period, any remaining Seller
Accounts Receivable shall be returned to Seller for collection and
Radio, LLC shall provide Seller with a photocopy of any checks made
payable to Buyer which included amounts included within Seller
Account Receivable; provided, however, that any payment of Seller's
Accounts Receivable received by Radio, LLC following the Collection
Period shall be promptly remitted to Seller.
4. Purchase Price and Method of Payment.
4.1 Purchase Price. The aggregate amount to be
paid to Seller by Buyers for the Purchased Assets shall be EIGHT
HUNDRED SEVENTY FIVE THOUSAND ($875,000) DOLLARS (the "Purchase
Price"), subject to adjustments as set forth in Section 5 below.
4.2 Method of Payment. The Purchase Price shall be
paid by Buyers on the Closing Date, as follows:
(i) the sum of FIVE HUNDRED THOUSAND ($500,000)
DOLLARS by wire transfer of immediately available funds to
such bank account(s) as Seller shall designate;
(ii) the execution and delivery of a TWO
HUNDRED SEVENTY FIVE THOUSAND ($275,000) DOLLAR Promissory
Note in the form attached hereto as Exhibit "H", payable,
together with interest at the rate of eight percent (8%),
quarterly over a period of ten (10) years, the first payment
being due and payable three (3) months following the Closing
Date; and
(iii) the execution with Seller and Seller's
Shareholders, of a Noncompetition Agreement in form and
substance substantially identical to that set forth at Exhibit
"F" (the "Noncompetition Agreement"), attached hereto, and
pursuant to which the aggregate sum of ONE HUNDRED THOUSAND
($100,000) DOLLARS will be paid, annually over a period of
ten (10) years.
4.3 Earnest Money Escrow Deposit. Buyers shall
deposit the sum of FORTY THREE THOUSAND SEVEN HUNDRED FIFTY
($43,750) DOLLARS with the Escrow Agent ("Escrow Deposit"), which
sum shall be held and disbursed in accordance with the provisions
of the Escrow Agreement. On the Closing Date, and the closing of
the transactions contemplated by this Agreement, all or part of the
Escrow Deposit plus accrued interest thereon may at the option of
Buyers be delivered to Seller and applied to the Purchase Price.
Provided that Buyers are not then in default in the performance of
their obligations under this Agreement, if Seller defaults in the
performance of its obligations hereunder, the Escrow Deposit plus
accrued interest thereon shall be returned to Buyers, and Buyers
may bring an action against Seller for its damages, and/or for
specific performance, or both. Provided that Seller is not then in
default in the performance of its obligations under this Agreement,
and if all conditions precedent to the closing of the transactions
contemplated herein shall have been satisfied, if Buyers default in
the performance of their obligations hereunder, Seller may receive
the Escrow Deposit plus accrued interest thereon as provided in the
Escrow Agreement, in which case the Escrow Deposit plus the accrued
interest shall constitute full and complete liquidated damages to
Seller from Buyers' said default and shall be Seller's sole and
exclusive remedy in the event this Agreement is terminated as a
result of Buyer's default hereunder.
5. Prorations. Operation of the Stations and all
income, expenses and liabilities attributable thereto through 12:01
a.m. on the Closing Date shall be for the account of Seller and
thereafter for the account of Buyers. All: (i) income and
expenses, including, but not limited to, such items as power and
utilities charges, ad valorem and other real and personal property
taxes and business taxes upon the basis of the most recent
assessment available; (ii) the Assumed Contracts to be assigned to
Licenses, LLC pursuant to Section 2.4; (iii) rents, wages and
salaries of employees, including accruals of bonuses, commissions,
sick pay and vacations of employees who are employed by Licenses,
LLC, and related payroll taxes; and (iv) other prepaid and deferred
items, shall be prorated between Seller and Buyers in accordance
with generally accepted accounting principles consistently applied,
the proration to be made and paid, insofar as determinable, on the
Closing Date, with a final proration settlement within sixty (60)
8
IN WITNESS WHEREOF, the Parties have caused this
Agreement to be executed by their duly authorized officers on the
day and year first above written.
SELLER:
BARDCOM, INC.
BUYERS:
MEGAHERTZ RADIO, LLC
BY:
AS ITS
MEGAHERTZ LICENSES, LLC
BY:
AS ITS MANAGER
44
~3/18/2002 M0N 15:27 FAX 202 728 0354
~L/24/200~TItlT 15:[2 FAX
IRWIN,CAMPBELL
[~004
~TZ Li~S~S, LLC
PROMISSORY NOTE
$275,000
2002
MEGAHERTZ RADIO, LLC and MEGAHERTZ LICENSES, LLC
(collectively "Makers"), promise to pay to the order of BARDCOM,
INC. ("Payee"), its successors and assigns, at 112 West Shirley
Street, Mt. Union, Pennsylvania 17066 (or such other place as Payee
may in writing designate to Makers), the principal sum of Two
Hundred Seventy Five Thousand ($275,000) Dollars, together with
interest thereon at a rate per annum equal to eight (8%) percent,
due and payable over a ten year period in 40 equal quarterly
installments of Ten Thousand Fifty Four ($10,054.00) Dollars, the
first of said installment due three (3) months from the date
hereof, with a like installment due every three (3) months
thereafter until paid in full.
The Makers of this Note shall have the right to prepay
without penalty all or any part of the principal or interest
indebtedness evidenced by this Note at any time.
Should:
(a) Makers fail to make any payment when due, after
thirty (30) days written notice of such non-payment from Payee
to Makers; or
(b) any Maker make an assignment for the benefit of
creditors, or apply to any tribunal for the appointment of a
trustee or receiver of any substantial part of their assets,
or commence any proceeding under any bankruptcy,
reorganization, arrangement, insolvency or similar law, or if
any such application is filed against any of them and such
party against whom such application is filed either indicates
approval, consent or acquiescence, or an order is entered
appointing a trustee or receiver, or adjudicating any Maker
bankrupt or insolvent or approving the petition in such
proceeding;
then Payee (or any holder of this Note) may declare all principal
and interest due and payable, and the same shall immediately become
due and payable.
Makers waive all demands for payment, presentations for
payment, notices of intention to accelerate maturity, notice of
acceleration of maturity, protest, and notices of protest, to the
extent permitted by law.
Should the Payee, or any holder of this Note, declare
immediately due and payable the entire indebtedness evidenced
hereby, principal and interest, Makers and each and every present
and future party hereto, including endorsers, acceptors, sureties,
and ~uarantors shall pay all costs of collection, including
2
reasonable attorney's fees, upon the amount due at the time of
making the collection if collected through the services of an
attorney.
Should Makers sell substantially all of the broadcasting
assets of Radio Stations WHUN(AM) and WXMJ(FM) acquired this date
from Payee, then all remaining indebtedness, principal and
interest, evidenced by this Promissory Note, shall immediately
become due and payable.
IN WITNESS WHEREOF, each Maker has caused this Promissory
Note to be executed by its authorized Member as of the ~q~day of
2002.
MAKERS:
MEGAHERTZ LICENSES, LLC
BY: ~EMBE~'
MEGAHERTZ RADIO, LLC
BY: A E' 'BER
03/18/2002 MON 1.5:28 FAX 202 728 0354
01/24/2001 TH'CT 15:14
IRWIN, CAMPBELL
FOR XrALUE RECEIVED, BARDCOM, INC., does, !this ,~ day of
f~regoing Promissory Note, and the indebtedness ev~.' de~ced, thereby,
to the following persons in the =ollo~in~ ~er=en=ages, to w~==
RON,~T~.P A. RABENA 35%
BP-lAN L- wILLIAHS 27.5%
DAVID & JACQUELIN B/kt.r. 6.25%
ALBERT RABENA
[~008
IN WITNESS WHEREOF, ~ARDCOM, INC- Has ¢=used this
A~i~nment to be executed 'the .day and year first above' written..
~SRDCo~ ~ INC.
MakerN hereby a~knowled~e receipt of the wit2ain and
Assignment, and ~ill hereafter makel principal and
i~i~erest payments un.~ler the t~rcmissory Note in acc~aance with' such
a~ ~gr~ment.
MEGAheRTZ RADIO, LLC
~zmmum~z LXCENSw. S, LLC
4
ASSIGNMENT
FOR VALUE RECEIVED, BARDCOM, INC., does, this ~day of
April, 2002, assign all of its interest in and to the foregoing
Promissory Note, and the indebtedness evidenced thereby, to the
following persons in the following percentages, to wit:
RONALD A. RABENA 35%
BRIAN L. WILLIAMS 27.5%
ANDREW M. HUNTER 25%
DAVID & JACQUELIN BALL 6.25%
ALBERT RABENA 6.25%
IN WITNESS WHEREOF, BARDCOM, INC. has caused this
Assignment to be executed the day and. year first above written.
BARDCOM, INC.
BY:
AS ITS PRESIDENT
Makers hereby acknowledge receipt of the within and
foregoing Assignment, and will hereafter make principal and
interest payments under the Promissory Note in accordance with such
assignment.
MEGAHERTZ RADIO, LLC
BY: AUTH~RiZED) M~EMBER
MEGAHERTZ LICENSES, LLC
BY: AUTHO~/R I~ED~ MEMBER
EXECUTION COPY
APRIL 12, 2002
NON-COMPETITION AGREEMENT
THIS AGREEMENT, made this ~ day of ~L' % , 2002
by and between MEGAHERTZ RADIO, LLC, ( "Buyer" ) , BARDCOM,
INC. ("Seller") , and RONALD A. RABENA, BRIAN L. WILLIAMS, ANDREW M.
HUNTER, DAVID & JACQUELIN BALL and ALBERT RABENA ( "Seller' s
Principals" ) .
W I T N E S S E T H:
WHEREAS, Buyer is the owner and operator of radio
stations WHUN-AM and WXMJ-FM, licensed respectively to Huntingdon,
Pennsylvania and Mt. Union, Pennsylvania (the "Stations"), having
acquired the Stations this date from Seller; and
WHEREAS, Buyer desires that Seller and Seller ' s
Principals be prohibited from owning any interest in any commercial
radio broadcasting station located within certain areas for a
period of five (5) years;
NOW, THEREFORE, in consideration of the mutual covenants
herein contained, the parties agree as follows:
1. Territory. The territory shall be the 1.0 mV/m
contour for each of the Stations.
2. Term. The term of this Agreement shall be fo~
period of five (5) years from its date ("Term").
3. Noncompetition Covenant.
(a) As a material inducement to Buyer to purchase
the Stations and pay Seller and Seller's Principals the amounts
provided for herein, Seller and Seller's Principals covenant and
agree that during the Term neither will, directly or indirectly,
engage in the following conduct within the Territory:
(1) Participate in any activity involved in the
ownership or operation of any radio station; or
(2) Solicit the business ,of any customer of the
Stations or Buyer or any entity or person whose
business Buyer has solicited or plans to solicit;
or
(3) Hire, attempt to hire or assist any other person or
entity in hiring or attempting to hire any employee
of Buyer or any person who was an employee of the
Stations during the one (1) year period immediately
prior to the execution of this Agreement; or
(4) Induce or attempt to induce any person to terminate
or leave employment with Buyer for any reason; or
(5) Take any action that interferes with or is not in
the best interests of the business (including
prospects for) of Buyer.
2
(b) As used herein,' "participate" means lending
money or one's name to, acting as a consultant or advisor to,
providing credit for, ~uaranteeing the debt of or providing
material assistance to, being employed by or acquiring any direct
or indirect interest in any business or enterprise, whether as a
stockholder, partner, venturer, lender, officer, director, employee
or otherwise in any other capacity as principal or agent or through
any other person or entity acting as nominee or agent, or by any
other means.
(c) For purposes of this paragraph 2, "Buyer" shall
refer to PA, LLC and any direct or indirect subsidiary or affiliate
thereof.
4. Station's Employees. In addition, Seller and
Seller's Principals will not directly or indirectly (whether as
partner or venturer, stockholder, or in any other capacity as
principal or agent or through any person, corporation, partnership,
entity or employee acting as nominee or agent), employ any person
or induce or attempt to induce any person to terminate employment
with the Buyer, who, on the date hereof is an employee of the
Seller and who at any time during the term of this Agreement,
becomes an employee of the Buyer; provided, that this restriction
shall not apply to any person whose engagement is terminated by the
Buyer for any reason, nor to any person who, having been employed
3
by the Buyer for twelve (12) months or more, voluntarily terminates
such employment. The restrictive provisions of this Agreement shall
not prohibit Seller or Seller's Principals from having an equity
interest in the securities of any corporation engaged in any
business and which is listed on a recognized Securities Exchange or
traded in the over-the-counter market to the extent that such
interest does not exceed one percent (1%) of such corporation and
does not constitute control of such corporation.
5. Consideration. As consideration for Seller and
Seller's Principals entering into this Agreement, Buyer shall pay
to Seller the sum of $1.00 and to Seller's Principals the aggregate
sum of One Hundred Thousand ($100,000) Dollars, payable Ten
Thousand ($10,000) Dollars annually for a period of ten (10) years,
commencing on the first anniversary of the date of this Agreement,
with payments to Seller's Principals being divided among them in
the respective percentages set forth below:
RONALD A. RABENA 35%
BRIAN L. WILLIAMS 27.5%
ANDREW M. RTINTER 25%
DAVID & JACQUELIN BALL 6.25%
ALBERT RABENA 6.25%
6. Confidential Information. Without the prior
written consent of Buyer, Seller and Seller's Principals will not
4
at any time, during or after the Term, furnish or make accessible
to any person, firm, corporation or other business entity all or
any part of any trade secret, technical data, confidential or
secret know-how or other information concerning the confidential
business practices, methods, processes, equipment or other
confidential or secret aspects of the business of Buyer, including
specifically that which relates to the Stations, or of any
subsidiary or affiliate of Buyer.
7. Entire Aqreement. This Agreement constitutes the
entire agreement between the parties concerning the subject matter
hereof, and there are no terms other than those contained herein.
No modification to this Agreement shall be deemed valid unless in
writing and signed by the party against whom enforcement is sought.
No discharge (by means other than performance) of a party's
obligations hereunder shall be deemed valid unless in the form of
a writing signed by the party who is alleged to have discharged the
other. No waiver by a party of any breach by the other party of
any provision or condition of this Agreement shall be deemed a
waiver of any other breach.
8. Notices. All notices, demands and requests, required
or permitted to be given under the provisions of this Agreement
shall be in writing and deemed duly given on the next business day
after being deposited with a nationally recognized overnight
delivery service for delivery on the next business day or upon
personal delivery or three (3) business days after being sent by
certified mail, postage prepaid, or when received by facsimile,
provided an additional copy is sent by one of the other methods set
forth herein addressed as follows:
8.1
If to Seller:
Bardcom, Inc.
112 West Shirley Street
Mt. Union, PA 17066
Attn: Ronald A. Rabena
Telephone: 814-542-8648
Fax: 814-542-8649
8.2
If to Buyers:
Megahertz Radio, LLC
c/o Robert F. Wright, Jr.
First Union Bank Building
699 Broad Street, 15th Floor
Augusta, GA 30901
Telephone: (706) 722-7542
Fax: (706) 724-7776
or any such other addresses as the Parties may from time to time
supply in writing.
9. Successors and AssiGns. This Agreement shall be
binding upon, and shall inure to the benefit of, the parties hereto
and their respective heirs, administrator, successors and assigns,
and the parties hereto may assign their rights and obligations
hereunder to another party or parties without the approval of the
other party. The covenants, conditions and provisions hereof are
6
and shall be for the exclusive benefit of the parties hereto and
their permitted assigns, and nothing herein, express or implied, is
intended or shall be construed to confer upon or give any person or
entity other than the parties hereto or their permitted assigns any
rights, remedy or claim, legal or equitable, under or by reason of
this Agreement.
Governing Law.
accordance
10.
enforced in
Pennsylvania.
11.
This Agreement shall be construed and
with the laws of the Commonwealth of
Counterparts.
counterparts and each shall be considered an original thereof.
This Agreement may be executed in
13. Acknowledqement by Seller and Seller's Principals.
Seller and Seller's Principals, as evidenced by the execution
by each of this Agreement, hereby expressly acknowledge that the
Term, the area covered, and the noncompetition covenant contained
in this Agreement are reasonable and reasonably needed for the
protection of Buyer.
14. Injunctive Relief.
Seller and Seller's Principals contained in this Agreement relate
The covenants and obligations of
12. Enforceability.
this Agreement may be invalid,
intended that the remaining parts insofar
reasonable shall be effective and enforceable.
To the extent that any part of
illegal or unenforceable, it is
as possible and
to matters which are of a special, unique and extraordinary
character and a violation of any of the terms of such Section will
cause irreparable injury to Buyer, the amount of which will be
impossible to estimate or determine and which cannot be adequately
compensated. Therefore, Buyer will be entitled, in addition to any
other remedies that may be available, to an injunction, restraining
order or other equitable relief from any court of competent
jurisdiction, restraining any violation or threatened violation of
any of such terms by Consultant and such other persons as the court
orders. The parties acknowledge and agree that judicial action,
rather than arbitration, is appropriate with respect to the
enforcement of the provisions of Section 2. The expenses of any
such injunctive proceeding shall be borne by the non-prevailing
party to the proceeding, including, but not limited to, attorneys
fees.
15. Severability. A breach by any of Seller's
Principals of the terms and provisions of this Agreement shall not
be deemed a breach by any other of Seller's Principals and will not
in any manner relieve Buyer of its obligations hereunder with
respect to Seller's Principals in compliance with this Agreement.
16. Acceleration. Should Buyer sell substantially all
the broadcasting assets of the Stations acquired this date from
Seller, then all remaining payments due hereunder shall immediately
8
become due and payable, at an amount equal to the then present
value, at an eight (8%) percent discount rate, of such remaining
payments.
IN WITNESS WHEREOF, the parties have hereunto set their
hands as of the date and year first above written.
MEGAHERTZ RADIO, LLC
SELLER'S PRINCIPALS:
RONALD A. RABENA
BARDCOM, INC.
BRIAN L. WILLIAMS
BY:
AS ITS
ANDREW M. HUNTER
DAVID BALL
JACQUELIN BALL
ALBERT RABENA
9
IN WITNESS WHEREOF, the parties have hereunto set their
hands am of the date and year first above written.
MEGAHERTZ RADIO, LLC
BY:
AS ITS
BARDCOM, INC.
SELLER'S PRINCIPALS:
~RbNALD A. RABENA
BRIAN L-'~WILLIAMS
ANDREW M. HUNTER
DAVID BALL
~f~B ERT RAB ENA
REV-1508 EX + (1-97)(1)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF RABENA, ALBERT
FILE NUMBER 21-03-0330
Include the proceeds o{ litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of sun/ivorship must be disclosed on Schedule F.
ITEM
NUMBER
DESCRIPTION
1994 Chrysler New Yorker
1988 Chrysler New Yorker Landau
Bequest from Last Will and Testament of Theodore A. Rabena. Unliquidated. It is unknown if any
sums will be realized and an amended return will be filed if sums are received.
Security Deposit from Woods
Blue Cross Reimbursement
VALUE AT DATE
OF DEATH
$3,800.00
$490.00
$1,920.00
$85.75
$6,295.75
TOTAL (Also enter on line 5, Recapitulation)
(If more space is needed, insert additional sheets of the same size)
: ZIMMERMAN;S AUTO WORLD SELINSGROVE, PA 17870
.VENDOR~ T~C~L]| !El TNE BALL
-, NAME
DATE INVOICE NO.
, ,! (':,3
SEQUENCE NUM.
' VENDOR
CHECK '~ '~ .'~; --- CONTROL
(MMS) NUMBER : z ~'J'~
; NUMBEF
AMOUNT r~ DATE INVOICENO.
!UELINE BALL
!UEL iNE BALL
38C, 0. OC, JAC¢~
38,-'_](.]. 00- JACr_.
3954
AMOUNT
DETACH AND RETAIN FOR YOUR RECORDS ~/0/'ti2003 TOTAL NET AMOUNT ~"
800. O0
ZIMMERMAN ENTERPRISES, INC.
CHRYSLER
June l 1, 2003 ~~//q]O ~
To Whom It May Concern:
On behalf of the family of Julius Rabena, we have been asked to appraise a
vehicle that he owned at the time of his death. The Vehicle is a 1988 Chrysler New
Yorker Landau, VIN 1C3BU6634JD218538 that is in average condition for the year.
This vehicle is no longer listed in most of the wholesale/retail value guide books.
Based on our experience and the condition of the vehicle, I would estimate a value of
$ 490.00 (Four Hundred and Ninety Dollars).
Respectfully
Robert C. Zimmerman Jr.
Sales, 1435 Market St., Sunbury, PA 17801 Phone (570) 286-2100, Fax (570) 988-5339
Service, Parts & Boclyshop - 1301 Market St. P.O. Box 490, Sunbury, Pa 17801
Phone - (570) 286-2100, Fax (570) 286-5117
FIVE STAR
LAST WILL AND TESTAMENT
OF
THEODORE A. RABENA
ae
Rebecca R. Wagner;
B.
I, THEODORE A. ~ABENA, of the Borough of New Cumberland,
Cumberland County, Pennsylvania, declare this to be my last will and
revoke any will previously made by me.
ITEM I: I make the following specific gifts:
My John Alden and Paul Revere Mutual accounts to
$55,000.00 and my Chrysler automobile to my brother
Albert Rabena and his wife Florence Rabena, as tenants by the
entirety;
C. $30,000.00, my Chevrolet automobile and my interest
in the property at 405 15th Street, New Cumberland, Pennsylvania to my
brother Julius Rabena;
D. $30,000.00 to my brother Edward Rabena and his wife
Betty Rabena, as tenants by the entirety;
E. $35,000.00 to the Trinity United Methodist Church
of New Cumberland, Pennsylvania;
F. $5,000.00 to my niece, Jackie Ball, $5,000.00 to
her husband, David Ball, $5,000.00 to their child, David Ball, and
$10,000.00 to their child, Niel.Ball;
Page 1 of 6
G. $5,000.00 to my nephew, Brian Rabena, $5,000.00 to
his wife, Cindy Rabena, $5,000.00 to their child, Joey Rabena, and
$5,000.00 to their child, Julie Rabena;
H. $5,000.00 to my niece, Karen Miller, $5,000 to her
husband, Russell Miller, $5,000.00 to their child, Camille Miller, and
$5,000.00 to their child, Justin Miller;
I. $15,000.00 to my nephew, Ron Rabena;
J- $5,000.00 to my nephew, Philip Rabena, $5,000.00 to
his wife, Judy Rabena, and $5,000.00 to their child, Beth Rabena;
K. My videos of New Cumberland and its history to the
Cumberland Library.
L.
M.
N.
$10,000.00 to the West Shore Kiwanis Club;
$35,000.00 to Jeff Brinton;
$15,000.00 to the New Cumberland Fire Department to
be used for fire truck restoration.
ITEM II: I give and devise my vacant lot behind my property at
418 Bridge Street, New Cumberland, Pennsylvania, to the New Cumberland
Fire Department upon the following terms and conditions:
A. No structure shall be erected on the paved or
asphalt portion of the lot;
B. A small plaque or marker shall be placed on the lot
commemorating the fact that the lot is a gift from the Rabena family;
Page 2 of 6
C. The present rent of $75.00 per month is to be
continued with the money being paid into an escrow account which the
New Cumberland Fire Department shall use from time to time to maintain
the lot in good condition;
D. The New Cumberland Fire Department shall constitute
a board of managers composed of two of the Rabena family so long any
two are living, a member of Fire Department's board of trustees, and
the person responsible for maintenance of the lot, and this board of
managers shall oversee the care of the lot;
E. The New Cumberland Fire Department must allow the
Trinity United Methodist Church to use the lot for parking on Sunday
mornings;
F. The New Cumberland Fire Department must allow Dr.
Cicarelli and the Green Hill Medical Clinic to rent the lot for
parking for the rest of this century (December 31, 1999); Green Hill
will be responsible for snow removal.
ITEM III: All the rest, residue and remainder of my estate I
give, devise and bequeath to Rebecca R. Wagner, of 409 S. 13th Street,
Harrisburg, Pennsylvania, if she survives me.
ITEM IV: I appoint Rebecca R. Wagner Executrix of this my last
Will.
ITEM V:
My executrix may delay the payment of the specific gifts
set forth in ITEM I if my estate is not sufficiently liquid to permit
the payment of such gifts in full within the normal time of adminis
Page 3 of 6
tration, and she may, in her sole discretion, pay portions of such
gifts on a pro rata basis from time to time until the necessary
liquidity is achieved.
ITEM VI: The gifts set forth in ITEM I shall be paid subject to
any inheritance taxes imposed thereon, and such taxes shall be deduct-
ed from those gifts 'and shall not be imposed upon the residuary gift
set forth in ITEM III.
ITEM VII: No fiduciary acting hereunder shall be required to
post bond or enter security for the faithful performance of his/her
duties in any jurisdiction.
IN WITNESS WHEREOF, I, THEODORE A. RABENA, have hereunto set my
hand and seal this ~ day of ~ ~' ,
1996.
THEODORE A. RABENA
SIGNED, SEALED, PUBLISHED and DECLARED by THEODORE A. RABENA, the
Testator above named, as and for his Last Will and Testament, and in
the presence of us, who at his request, in his presence and in the
presence of each other, have subscribed our names as witnesses.
Witness ' " Address
Witness
Addre s s
Page 4 of 6
COMMONWEALTH OF PENNSYLVANIA:
:SS:
COUNTY OF CUMBERLAND :
I, Theodore A. Rabena, the Testator whose name is signed to the
attached or foregoing instrument, having been duly qualified according
to law do hereby acknowledge that I signed and executed this instru-
ment as my last will; that I signed it willingly and that I signed it
as my free and voluntar~ act for the purposes therein contained.
THEODORE A. RABENA
Sworn to or affirmed to and acknowledged before me by Theodore A.
Rabena, the Testator, this c~~'P~ day of ~'~'-~-~ , 1996.
Notary Public
Page 5 of 6
COMMONWEALTH OF PENNSYLVANIA :
COUNTY OF CUMBERLAND
:SS:
:
the witnesses whose names are signed to the attached or foregoing
instrument, being duly qualified according to law, depose and say that
we were present and saw Testator sign and execute the instrument as
his last will; that Testator signed willingly and that he executed it
as his free and voluntary act for the purposes therein expressed; that
each of us in the hearing and sight of the Testator signed the will as
witnesses; that to the best of our knowledge, the Testator was at that
time eighteen or more years of age, of sound mind and under no con-
straint or undue influence.
Witness
Witness
Sworn to or affirm-ed to and acknowledged before me by
witnesses, this ~f~ day of
and ~'~,'I//,.¢'/-.3 /L-/. /--/j,,,T/~ L
'-':
Notary Public
Page 6 of 6
THE WOODS AT CEDAR RUN/G.C.C.C.
Albert Rabcna
1301~0 · A/R - Tenants/Commerc/Related
4/10/2003
6165
1,920.00
M & T -General Account Refund Tenant Security Deposit - Plus overpayment March
1,920.00
Membersl
FEDERAL CREDIT LrNION
P.O. Box 40 · Mechanicsburg, PA 17055-0040
(717) 697-1161
TOLL FREE (800) 283-2328
www.memberslst.org
NCUA
The Woods at Cedar Run \ GCCC
824 Lisbum Road
Camp Hill, PA 17011
CUSTOMER
Albert Rabena
824 Lisbum Road
Apt. # 619
Camp Hill, PA 17011
Credit Memo
DATE CREDIT NO.
3/18/2003 6743
Tenant Security Deposit
DESCRIPTION
QTY
P.O. NO. PROJECT
RATE
1,845.00
AMOUNT
-I,845.00
Total
$-1,845.00
Invoice
The Woods at Cedar Run \ GCCC
824 Lisburn Road
Camp Hill, PA 17011
DATE INVOICE #
3/1/2003 6711
BILL TO
Albert Rabena
824 Lisburn Road
Apt. # 619
Camp Hill, PA 17011
TERMS DUE DATE ROOM NUMBER AMOUNT
Net 5 3/6/2003 619 1695.00
DESCRIPTION QTY RATE [~ AMOUNT
Residential Apartment - One Bedroom 1,845.00 1,845.00
Meal crexlit - 2/3 thru 3/31/03 - Residential 2 -75.00 -150.00
Apartment - One Bedroom
REVISED BILLING
Total $1,695.00
REV-1509 EX + (1-97)(1)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF RABENA, ALBERT FILE NUMBER 21-03-0330
If an asset was made joint within one' ~ear of the decedent's date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT
A. Jacqueline R. Ball Daughter
110 Sunrise Avenue
New Cumberland, PA 17070
JOINTLY-OWNED PROPERTY:
ITEM L~- ~ ~ ~-h: DATE DESCRIPTION OF PROPt=t~ i Y % OF DATE OF DEATH
NUMBER FOR JOINT MADE Include name of financial institution and bank account number or similar identifying number. DATE OF DEATH DECD'S VALUE OF
TENANT JOINT Attach deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENTS INTEREST
1. A. 1/12/02 PNC Savings Account, Account No. 51-4005-1144 $11,660.59 100% $11,660.59
51-3004-2033 $14,552.23 100% $14,552.23
TOTAL (Also enter on line 6, Recapitulation) $26,212.82
(If more space is needed, insert additional sheets of the same size)
Tot Banking Statement
PNC ~ank
For ~oporiod04/08/2003to 0~07/2003
JACQ~,A 8ALL
110~DR
NEN CUHBERLAND PA 17070-$059
Relationship Overview
Bank Deposit Accounts
PNCBANK
Primary account number: 5%4005-1144
Page 1 of 3
Number of enclosures: 0
'~' For 24-hour customer service or
current rates: Call 1-888-PNC-BANK
Moving? Please contact us at 1-888-PNC-BANK
I~] Write to: Customer Service
PO Box 609
Pittsburgh PA 15230-9738
&~ Visit us at www.pncbank.com
~TDD terminal: 1-800-531-1648 For hearing hnpaired clients only'
)ascription Account Number
~nterest Checld~g 51-4005-1144 Deposit Balance
~avings 51-3004-2035 .00
l'otal Deposits .00
.00
d
Win with Email from PNC
Learn about spedal offers from PNC. Get articles and calculators to help you make informed finandal decisions. Take advantage
)f PNC Web-only offers. Get information about PNC products and services. All delivered directly to your email inbox. To learn
nore about the benefits of email from PNC and our limited time special email promotion, visit www.pncbank.com/winwithemail
Dr call us at 1-800-762-2105 or sign on to Account Link today.
Interest Checking Account Summary
~ccount number:. 51-4005-1144 Account Link ~ number:. 0168367174
~alance S.,~ary
Beginning Deposits and Checks and other Ending
balance other additions deductions balance
1,660.46 .13 11,660.59 .00
Average monthly Charges
balance and fees
777.36 .00
'~a~saction Summary
Checks paid/ Bank card/POS Account Information Teller
~ withdrawals transactions assistance calls transactions
: 1 0 0 l
.~ Total ATM PNC Bank MAC Other MAC ATM Other ATM
transactions ATM transactions transactions transactions
0 0 0 0
aterest S~mmary
Annual Percentage Number of days Average collected Interest Earned
Yield Earned (APYE) in interest period balance for APYE this period
0.207. 2 11,660.46 .13
Withholding Interest eamed Withholding
this period year-to-date year-to-date
.03 9.08 .66
Jacqueline A Ball
Please see the Activity Detail section for
additional information.
As of 05/07, a total of $9.08 in interest was
earned this year.
FORM953R
,Total Banking Statement
For 2~hour customer service:
Call: 1-888-PNC-BANK
Account numbe~. 51-400g1144 - continued
For the period 04/08/2003 to 05/07/2003
JACQUELINE A BALL
Primary account number: 51-4005-1144
Page 2 of 3
Activity Detail
Deposits and 'Other Ad(dfons
Date Amount DescriPt?o~n !
04/10 .13 Interegt Payment
Other Deductions
Date Amount
04/10 .03
04/10 .00
04/10 11,660.56
Description
Interest Withholding
Outstanding Item Close
Withdrawal Tel 0400010901 0539
There was 1 Deposit or Other Addition
totaling $.13.
There were 3 Other Deductions totaling
$11,660.59.
Daily Balance Detail
Date Balance Date Balance
04/08 l 1,660.46 04/10 .00
Move Up To A Checking Package Plan And Broaden Your financial Horizons
If your financial needs include more than just checking, why not make the most of your banking relationship by upgrading to a
PNC Bank Choice Plan® or Premium Plan®. Depending on the plan you choose, you can combine balances of other PNC
accounts, such as savings, checking and loans to qualify for a waiver of the applicable monthly service charge. Both package plans
provide you with additional free!~ervices like free checks and free online banking and added discounts on other products. Stop
by your local branch today or call 1-888-PNC-BANK, anytime, and ask about all the benefits of having a PNC Package Plan.
Sa~i-gs Accou. t S~i.mary
Account number. 5%3004-2033 Account Link ® number. 0168367174
Balance Summary
Beginning Deposits and
balance other additions
14,552.23 .28
Checks and other Ending
deductions balance
14,552.51 .00
Average monthly Charges
balance and fees
970.14 .00
Transaction Summary
Checks paid/ Bank card/POS
withdrawals transactions
! 0
Total ATM :'~': PNC Bank MAC
transactions . ATM transactions
0 0
Account Information Teller
assistance calls transactions
0
Other MAC ATM Other ATM
transactions transactions
0 0
Interest Summary
Annual Percentage
Yield Earned (APYE)
0.35Z
Number of days Average collected Interest Earned
in interest period balance for APYE this period
14,552.23 .28
Withholding Interest earned Withholding
this period year-to-date year-to-date
.08 16.93 1.37
Jacqueline A Ball
Please see the Activity Detail section for
additional information.
As of 05/07, a total of $16.93 in interest was
earned this year.
otal.Banking Statement
Fbr 24-hour customer service:
Call: 1-888-PNC-BANK
Account number: 51-3004-2033 - continued
Activity Detail
PNCBAN<
For tho period 04/08/2003 to 05/07/2003
JACOUEMNE A BALL
Primary account number. 51-4005-1144
Page 3 of 3
DepG~R~ and Ct:,er Ad4iiions
Date Amount Description
04/10 .28 Interest Payment
Deductions
Date Amount
O4/lO .o8
04/10 .00
04/10/ 14,552.43
Da,3y B~:~ce
Description
Interest Withholding
Outstanding Item Close
Withdrawal Tel 0400010901 0538
There was 1 DepOsit or Othbr Addition
totaling $.28.
There were 3 Other Deductions totaling
$14,ss2.sl.
Date Balance
04/08, 14,552.23
Date Balance
04./10 .00
FORMg~3R
Reviewing Your Statement
Please review this statement carefully and reconcile it with your records. Call the telephone number on the upper fight side of the first page of this
statement if:
· you have any questions regarding your account(s);
· your name or address is incorrect;
· you have a business account and your tax identification number is missing or incorrect;
· you have any questions regarding interest paid to an interest-bearing account.
Balancing Your Accodfit
Update Your Account Register ,
Compare:
Check Off:
Add to Your AccoUnt Register
Balance:
Subtract From Your Account
Register Balance:
The activity detail section of your statement to your account register.
All items in your account register that also appear on your statement. Remember to begin with the
ending date of your last statement. (An asterisk [*] will appear in the Checks section ff there is a gap in
the listing of consecutive check numbers.)
Any deposits or additions including interest payments and ATM or electronic deposits listed on the
statement that are not already entered.
Any account deductions including fees and ATM or electronic deductions that are not already entered.
Update Your Statement Information
Date of Deposit Amount
Total A
Step 1:
Add together
deposits and
other additions
listed in your
account re~ster
but not on your
statement.
Step 2:
Add together
checks and other
deductions listed
in your account
register but not
your statement.
Step 3:
Enter the ending balance recorded on your statement $
Add deposits and other additions not recorded Total A + $
Subtotal= $
Subtract checks and other deductibns not recorded Total B - $
The result should equal your account register balance = $
Check Number or
Deduction Description Amount
Total B
Verification of Direct Deposits
To verify whether a direct deposit or other transfer to your account has occurred, call us at the 24-hour customer service telephone number listed on the
upper fight side of the first page of this statement.
ElectrOnic Funds Transfers "'
In case of errors or questions about your electronic transfers or if you need more information about a transfer, call us at the 24-hour customer service telephone number listed on t-he
upper right side of the first page of this statement. Or, if you prefer, please write us at: Customer Service, P.O. Box 809, Pittsburgh, PA 15230-0609. If there is a problem, you must
contact us no later than 60 days after the ending date of the first statement on which the error or problem appeared. You will need to provide the following information:
* Your n,xme and account number(s);
· A description of the error or the transfer you are questioning. Please explain as clearly as you can why you need more information or why you believe an error was made;
· The dollar amount of the suspected error.
We will investigate your complaint and will correct any error promptly. If the investigation takes longer than 10 business days, we will credit your account for the ~mount you think i~
in error, so that you will have use of the funds during the time it takes us to complete our investigation.
Member FDIC ~ Equal Housing Lender
JOINT',ACCOUNT NOTIFICATION
OF NEW SOOAL SECUR1TY NUMBER
PNC Bank, National Association
Pittsburgh, PA 15265
PNCBAN<
To avoid tax withholding, fill out completely, sign, and return to the PNC Bank CIF department in the enclosed envelope immediately.
We recently learned that the primary owner of the accounts listed below passed away, and we extend our sincere condolences. As a joint owner
of the accounts listed, we are required, by law, to inform you of this important matter immediately.
The interest-earning accounts noted below are not listed under your social security number, so PNC Bank, N.A., is required to begin withholding
31O/o interest in these accounts for federal income tax purposes. As the joint owner, you can avoid this tax withholding by immediately
sending us your social security number and signature on this form.
If you would like to add another name to this account or close the account, you must bring this notice to the PNC Bank office listed next to
each account and a representative will assist you.
To Complete this Form:
Fill in your name and social security number; sign and date the form; and return to PNC Bank in the enclosed envelope.
· Interest earned on the accounts listed at the bottom of this page will now be reported to the IRS using your social security number.
· If you are unable to certify to 1) and 2) under A below, do not send in this form. You must come into the office where the account was
opened.
INTEREST AND DIVIDEND TAX COMPLIANCE ACT OF 1983
BACKUP WITHHOLDING CERTIFICATION
In order to avoid imposing backup withholding with respect to accounts that are opened on or after January 1, 1984, the Bank (the payor)
must obtain the following certification. Failure to provide this information may also subject the account owner (payee) to certain Internal
Revenue Service penalties, in addition to withholding.
A. TAX COMPUANCE CERTIFICATION
UNDER PENALTIES OF PERJURY, I CERTIFY:
1) that the social security number herein furnished to the Bank is my correct number, and
2) that I am not subject to backup withholding either because I have not been notified by the Internal Revenue
Service that I am subject to backup withholding as a result of a failure to report all interest or dividends, or the
IRS has notified me that I am no longer subject to backup withholding.
3) I am a U.S. person (including a U.S. resident alien)
Name 15ocial Security Number
I
Signature of U.S. Person I Date
X
IPrimary Owner Joint Owner
/d-K /o !
Prepared by CIF Department
IDate
FORMII3627-0302
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF RABENA, ALBERT FILE NUMBER 21-03-
0330
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
DESCRIPTION
FUNERAL EXPENSES:
Parthemores
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative (s)
Social Security Number(s) / EIN Number of Personal Representative(s)
Street Address
City State Zip
Year(s) Commission Paid:
Attorney Fees
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State ~ Zip
Relationship of Claimant to Decedent
Probate Fees Cumberland Law Journal, The Patriot News
Register of Wills
Accountant's Fees
Tax Return Preparer's Fees
:3iller's Disposal (household items)
TOTAL (Also enter on line 9, Recapitulation)
(If more space is needed, insert additional sheets of the same size)
AMOUNT
$8,077.00
$2,000.00
$304.33
$275.00
$36.25
$10,692.58
CUMBERLAND LAW JOURNAL
32 SOUTH BEDFORD STREET
CARLISLE, PA 17013
MAY 23, 2003
Cumberland Law Journal is published every Friday by the Cumberland County Bar
Association and is designated by the Court of Common Pleas as the official legal publication for
Cumberland County and the legal newspaper for publication of legal notices.
TO:
Barbara Sumple Sullivan, ESQUIRE
Albert Rabena, ESTATE
Legal advertisements must be received by Friday Noon. All legal advertising must be
paid in advance. Make all checks payable to: Cumberland Law Journal.
Advertisement inserted on following dates:
MAY 9, 16, 23, 2003
Advertising Cost
Proof of Publication
Second Proof Request
Payment Received
Total Amount Due
Payment received MAY 23, 2003
by Becky_ H. Morgenthal/Executive Director
$ 75.00
$ 0.00
$ 0.00
$ 75.00
$ 0.00
PROOF OF PUBLICATION OF NOTICE
IN CUMBERLAND LAW JOURNAL
(UnderAct No. 587, approved May 16, 1929), P. L.1784
STATE OF PENNSYLVANIA :
:
COUNTY OF CUMBERLAND :
SS.
Lisa Marie Coyne, Esquire, Editor of the Cumberland Law Journal, of the County and
State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law
Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid,
was established January 2, 1952, and designated by the local courts as the official legal
periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly
issued weekly in the said County, and that the printed notice or publication attached hereto is
exactly the same as was printed in the regular editions and issues of the said Cumberland Law
Journal on the following dates,
viz:
MAY 9, 16, 23, 2003
Affiant further deposes that he is authorized to verify this statement by the Cumberland
Law Journal, a legal periodical of general circulation, and that he is not interested in the subject
matter of the aforesaid notice or advertisement, and that all allegations in the foregoing
statements as to time, place and character of publication are tree.
Rabena, Albert, dec'd.
Late of 402 Fifteenth Street, New
Cumberland.
Executrkm Jacqueline R. Ball, I l0
Sunrise Avenue, New Cumber-
land, PA 17070.
Attorney: Barbara Sumple-Sul-
livan, Esquire, 549 Bridge Street,
New Cumberland, PA 17070,
(717) 774-1445.
SWORN TO AND SUBSCRIBED before me this
23 day of MAY, 2003
CLASSIFIED
~ .... ADVERTISING
INVOICE
Questions regarding this invoice call (717) 255-8138
To Place your ad Call Classified (717) 255-8121
Tearsheet Request call (717) 255-8417
THE PATRIOT NEWS
THESUNDAY PATRIOT NEWS
Proof of Publication
Under Act No. 587, Approved May 16, 1929
Commonwealth of Pennsylvania, County of Dauphin} ss
JOSEPH A. DENNISON being duly sworn according to law, deposes and says: That he is the Asst.
Controller of The Patriot News Co., a corporation organized and existing under the laws of the Commonwealth of
Pennsylvania, with its principal office and place of business at 812 to 818 Market Street, in the City of Harrisburg,
County of Dauphin, State of Pennsylvania, owner and publisher of The Patriot-News and The Sunday Patriot-News
newspapers of general cimulation, printed and published at 812 to 818 Market Street, in the City, County and State
aforesaid; that The Patriot-News and The Sunday Patriot-News were established March 4th, 1854, and September
18th, 1949, respectively, and all have been continuously published ever since;
That the printed notice or publication which is securely attached hereto is exactly as printed and published in
their regular daily and/or Sunday/ Metro editions which appeared on the 2nd, 9th and 16th day(s) of May 2003.
That neither he nor said Company is interested in the subject matter of said printed notice or advertising, and that
all of the allegations of this statement as to the time, place and character of publication are true; and
That he has personal knowledge of the facts aforesaid and is duly authorized and empowered to verify this
statement on behalf of The Patriot-News Co. aforesaid by virtue and pursuant to a resolution unanimously passed and
adopted severally by the stockholders and board of directors of the said Company and subsequently duly recorded in
the office for the Recording of Deeds in and for said County of Dauphin in Miscellaneous Book "M",
Volume 14, Page 317.
PUBLICATION
COPY
ESTAT~'NOTicE .
~..: NOTICE lis HEREB~GIVEN that L6t.
~ Testamentary: have been 9ranted 1~
ESTATE OF ALBERT RABENA, late o
PifteenthStreet, NeW C~berlan.~ C.u.e~%r
land County; Pe~n=Yl~anla, Who ama:
sunrise Avenue, NeW Cumbermn~j_curn~e
land countY, pennS~!~nl= ~; ' : :-:
required ta~n~ke payment, Qn~l_ those hay!..._
Claim= ec demands'tapresent the same
Ne~ Cumberl~ PA 1/~7~'
:(717):T]4.1M5~ :: ~ ~_: ~..
c~,~:l be'fore,r,. ' A.D.
City Of Harrisburg, Daupl~n County ' '--- - " - lC
My Commission Expires June 6, 2006 I NO~RY PUBL C
Member. Pennsylvania Association Of Notaries My commission expires June 6, 2006
BARBARA SUMPLE-SULLIVAN
549 BRIDGE STREET
NEW CUMBERLAND, PA. 17070
Statement of Advertising Costs
To THE PATRIOT-NEWS CO., Dr.
For publishing the notice or publication attached
hereto on the above stated dates
Probating same Notary Fee(s)
Total
$ 227.58
$ 1.75
$ 229.33
Publisher's Receipt for Advertising Cost
The Patriot News Co., publisher of The Patriot-News and The Sunday Patriot-News, newspapers of general
circulation, hereby acknowledge receipt of the aforesaid notice and publication costs and certifies that the same have
been duly paid.
REV-1512 EX + (1-97)(1)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF RABENA, ALBERT FILE NUMBER 21-03-0330
Include unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION AMOUNT
2.
3.
4.
5.
6.
7.
8.
Silver Spring Ambulance and Rescue Association
Woods (rent)
Person - 2002 Lower Allen
Federal Income ($1,273.00 + $356.57)
Pa. Income Tax ($368.00 + $31.90)
Utilities
Internist of Central PA
Albert Pharmacy Services, Inc.
$85.75
$1,770.00
$9.80
$1,629.57
$399.90
$22.27
$165.00
$82.53
TOTAL (Also enter on line 10, Recapitulation) $4,164.82
(If more space is needed, insert additional sheets of the same size)
Silver Spring Ambulance & Rescue Association
P.O. Box 726, New Cumberland, PA 17070-0726
717 214-6018 Toll Free 877 214-6018
Patient name: RABENA, ALBERT
JACQUELINE BOLL
110 SUNRISE AVE
NEW CUMBERLAND, PA 17070-3053
From:
To:
Primary payor:
Secondary payor:
Patient SSN: 172-01-0352
Run number: 03-1o41
Date of call: 2/20/2003
Time of call: 16:08
Caller:
Holy Spirit Hospital
HEALTHSOUTH MECHANICSBURG REHA
HGSAdministrators
172-01-0352-A
PA Federal Blue Cross
R00782203
Description
Basic Life SupportJNon-Emergen
Mileage
Contractual Allow - Medicare
Contractual Allow - Medicare
Payment - Cash
Contractual Allow - Medicare
Payment - Cash
Payment - To Client
Check #
880779562
880779562
Quantity
Unit price Payment date
300.00
7.50
2/20/2003
2/20/2003
5/1/2003
2/20/2003
5/2/2003
512/2003
Amount
300.00
45.00
-127.76
-19.86
-159.14
1.54
159.14
-159.14
PLEASE PAY THIS AMOUNT:
$39.78
Silver Spring Ambulance & Rescue Association
P.O. Box 726, New Cumberland, PA 17070-0726
717 214-6018 Toll Free 877 214-6018
Patient name: RABENA, ALBERT
ALBERT RABENA
824 LISBURN RD
APT 619
CAMP HILL, PA 17011
From:
To:
Primary payor:
Secondary payor:
Patient SSN: 172-01-0352
Run number: 03-1041
Date of call: 2/20/2003
Time of call: 16:08
Caller:
Holy Spirit Hospital
HEALTHSOUTH MECHANICSBURG REHA
Bill Patient
Description
Basic Life Support/Non-Emergen
Mileage
Check# Quantity Unit price Payment date Amount
1 300.00
6 7.50
300.00
45.00
PLEASE PAY THIS AMOUNT: $345.00
Silver Spring Ambulance & Rescue Association
P.O. Box 726, New Cumberland, PA 17070-0726
717 214-6018 Toll Free 877 214-6018
Patient name: RABENA, ALBERT
ALBERT RABENA
824 LISBURN RD
APT 619
CAMP HILL, PA 17011
From:
To:
Primary payor:
Secondary payor:
Patient SSN: 172-01-0352
Run number: 03-1041
Date of call: 2/20/2003
Time of call: 16:08
Caller:
Holy Spirit Hospital
HEALTHSOUTH MECHANICSBURG REHA
Bill Patient
Description
Basic Life Support/Non-Emergen
Mileage
Check #
Quantity
Unit price Payment date
1 300.00
6 7.50
Amount
300.00
45.00
PLEASE PAY THIS AMOUNT:
$345.00
DETACH ALONG ABOVE LINE AND RETURN STUB WITH YOUR PAYMENT. THANK YOU.
Patient name:
Patient SSN:
Remit to:
RABENA, ALBERT
172-01-0352
Run number: 03-1041
Current date: 03/20/2003
Silver Spring Ambulance & Rescue Association
P.O. Box 726
New Cumberland, PA 17070-0726
Amount I $
enclosed:
Due on: 3/30/2003
***Second Request*** In order to bill Medicare, the enclosed form must be completed, signed and returned to our office
within 10 days. Failure to return this form could result in referral of your account to collection.
L,, U U 1U"J /
Department of the Treasury
Internal Revenue Service
PHILADELPHIA, PA 19255-0010
SBW
28221-137-18507-$ 200523 CP: 2
Date of this notice: JUNE 16, 2005
Taxpayer Identifying Number 172- 01 - 0 $ 52
Form: 10q0 TaxPeriod: DEC, 31, Z002
h,hh,h,,,,,hl,hlhllh,,,,,,I,h,l.,h,,,,,,hlh,,,lllhl
ALBERT DECD & FLORENCE DECD RABENA
JACQUELINE R BELL EXEC
110 SUNRISE AVE
NEW CUMBERLND PA 17070-3055103
For assistance you may
call us at:
1-800-829-837q
CALLER ID= 96q261
WE CHANGED YOUR ESTIMATED TAX TOTAL - YOU HAVE AN AMOUNT DUE
WE CHANGED YOUR 2002 RETURN. AS A RESULT OF THESE CHANGES, YOU OWE
$356.57 AS SHOWN IN YOUR TAX STATEMENT BELOW. IF YOU THINK WE MADE A
MISTAKE, PLEASE CALL US AT THE NUMBER LISTED ABOVE. WHEN YOU CALL, PLEASE HAVE
YOUR PAYMENT INFORMATION AND A COPY OF YOUR TAX RETURN AVAILABLE. THIS
INFORMATION WILL HELP US FIND ANY PAYMENT YOU MADE THAT WE HAVEN'T APPLIED.
YOUR TAX STATEHENT
ADJUSTED GROSS INCOME ON RETURN
TAXABLE INCOME ON RETURN
$62,$20.00
q6,670.00
PAYMENTS AND CREDITS
TAX WITHHELD
ESTIMATED TAX PAYMENTS
OTHER CREDITS
OTHER PAYMENTS
TOTAL PAYMENTS & CREDITS
~3,669.00-
.00
.00
1,273.00-
$~,9q2.00-
TAX
TOTAL TAX ON RETURN
CORRECTED TAX ON RETURN
5,1q2.00
5,1~2.00
UNDERPAYMENT OF TAXES
PLUS:
PENALTY
INTEREST
AMOUNT YOU OWE
SUBTRACT PAYMENTS WE HAVENmT
INCLUDED
YOU OWE THE ADJUSTED AMOUNT
8.27
~356.57
PLEASE PAY THE FULL AMOUNT BY JULY 7, 2003. IF YOUmVE ALREADY PAID YOUR TAX
IN FULL OR ARRANGED FOR AN INSTALLMENT AGREEMENT, PLEASE DISREGARD THIS NOTICE.
IF YOU HAVENmT PAID, MAIL YOUR CHECK OR MONEY ORDER AND THE TEAR-OFF STUB
FROM THE LAST PAGE OF THIS NOTICE. MAKE YOUR CHECK PAYABLE TO UNITED STATES
TREASURY AND WRITE YOUR SOCIAL SECURITY NUMBER ON IT. IF YOU CAN'T PAY IN FULL,
PLEASE CALL US TO DISCUSS PAYMENT.
PAGE 1
L:UU/U~
PHILADELPHIA SERVICE CENTER
172-01-0552
TAX PERIOD: DEC. 31, 2002
CHANGE EXPLANATION(S)
YOU CLAIMED AN INCORRECT AMOUNT AS ESTIMATED TAX PAYMENTS AND CREDITS.
CREFER TO THE FOLLOWING STATEMENT OF YOUR ESTIMATED TAX ACCOUNT.)
OUR RECORD5 DON~T SHOW ANY ESTIMATED TAX CREDITS FOR SOCIAL SECURITY NUMBER
172-01-0352.
PLEASE CHECK TO SEE IF YOU NEED TO ADJUST YOUR ESTIMATED TAX PAYMENTS IF
YOUR TAX WAS REFIGURED.
EXPLANATION OF PENALTY AND INTEREST CHARGES
THE PENALTY AND INTEREST CHARGES ON YOUR ACCOUNT ARE EXPLAINED ON THE FOLLOWING
PAGES. IF YOU NANT A MORE DETAILED EXPLANATION OF YOUR PENALTIES AND INTEREST,
PLEASE CALL US AT THE TELEPHONE NUMBER LISTED ON THE TOP OF THIS NOTICE.
4152.57 FILING AND PAYING LATE - IRC SECTION 6651
NE CHARGED A COMBINED PENALTY BECAUSE YOU FILED LATE AND DIDN"T PAY YOUR TAX
BY THE DUE DATE OF YOUR RETURN. IF YOU THINK WE SHOULD REMOVE OR REDUCE THIS
PENALTY, SEE "REMOVAL OF PENALTIES - REASONABLE CAUSE."
THE FOLLOWING TABLE SHOWS THE PENALTY CHARGES ON YOUR ACCOUNT. TO COMPUTE YOUR
FILING AND PAYING LATE PENALTY NE USED PRINCIPAL X RATE X NUMBER OF MONTHS LATE.
Date ND.Months Rate/Month PrAncipal Penalty
06/15/2003 02 q.50X 1,q73.00 132.57
Total Penalty: 132.57
$15.73 PAYING LATE - IRC SECTION 6651
WE CHARGED A PENALTY BECAUSE YOU DIDN'T PAY YOUR TAX ON TIME. INITIALLY,
THE PENALTY IS 1/2% OF THE UNPAID TAX FOR EACH MONTH OR PART OF A MONTH YOU
DIDN'T PAY YOUR TAX. IF YOU THINK WE SHOULD REMOVE OR REDUCE THE PENALTY, SEE
"REMOVAL OF PENALTIES - REASONABLE CAUSE."
THE FOLLOWING TABLE SHOWS THE PENALTY CHARGES ON YOUR ACCOUNT. TO COMPUTE YOUR
LATE PAYING PENALTY WE USED PRINCIPAL X RATE X NUMBER OF MONTHS LATE.
Date ND.Months Rate/Month Principal Penalty
06/15/2003 02 0.50% 1,q73.00 lq.73
07/15/2003 O1 0.50% 200.00 1.O0
Total Penalty: 15.73
48.27 INTEREST - IRC SECTION 6601
WE CHARGE INTEREST WHEN YOUR TAX ISN'T PAID ON TIME. INTEREST IS
COMPUTED FROM THE DUE DATE OF YOUR RETURN (REGARDLESS OF EXTENSIONS)
UNTIL PAID IN FELL OR TO THE DATE OF THIS NOTICE.
INTEREST COMPOUNDS DAILY EXCEPT ON LATE OR UNDERPAID ESTIMATED TAXES FOR INDIVIDUALS
OR CORPORATIONS. INTEREST IS ALSO CHARGED ON PENALTIES FOR LATE FILING, OVER OR
UNDERSTATING VALUATIONS, AND SUBSTANTIALLY UNDERSTATING THE TAX YOU OWE.
THE FOLLOWING TABLE SHOWS THE INTEREST CHARGES ON YOUR ACCOUNT. TO COMPUTE YOUR
INTEREST WE USED PRINCIPAL X FACTOR.
From Date To Date Days Rate Factor Principal Interest
0q/I572005 05/1~/2003 $1 5.0Z 0.00q255313 1605.57 6.83
05/16/2003 06/16/200~ 31 5.0Z 0.00q255315 339.q0 1.qq
Total Interest: 8.27
ADDITIONAL INTEREST CHARGES
IF THE AMOUNT YOU OWE IS ~100,000 OR MORE, PLEASE MAKE SURE THAT WE RECEIVE YOUR
PAYMENT WITHIN 10 WORK DAYS FROM THE DATE OF YOUR NOTICE. IF THE AMOUNT YOU OWE IS
LESS THAN 4100,000, PLEASE MAKE SURE THAT WE RECEIVE YOUR PAYMENT WITHIN 21 CALENDAR
DAYS FROM THE DATE OF YOUR NOTICE. IF WE DONmT RECEIVE FULL PAYMENT WITHIN THESE
TIME FRAMES, THE LAW REQUIRES US TO CHARGE INTEREST UNTIL YOU PAY THE FULL AMOUNT
YOU OWE.
PAGE 2
CO0109Z
PHILADELPHIA SERVICE CENTER
172-01-0552
TAX PERIOD:
CP: 23
DEC. 31, 2002
REHOVAL OF PENALTIES - REASONABLE CAUSE
THE LAW LETS US REMOVE OR REDUCE THE PENALTIES EXPLAINED IN THIS NOTICE IF YOU
HAVE AN ACCEPTABLE REASON. IF YOU BELIEVE YOU HAVE AN ACCEPTABLE REASON, YOU MAY
SEND US A SIGNED STATEHENT EXPLAINING YOUR REASON. WE'LL REVIEW IT AND LET YOU
KNOW IF WE ACCEPT YOUR EXPLANATION AS REASONABLE CAUSE TO REMOVE OR REDUCE YOUR
PENALTY. THIS PROCEDURE DOESN"T APPLY TO INTEREST AND, IN SOME CASES, WE MAY ASK
YOU TO PAY THE TAX IN FULL BEFORE WE REDUCE OR REMOVE THE PENALTY FOR PAYING LATE.
ERRONEOUS WRITTEN ADVICE FROM IRS
WE'LL ALSO REMOVE YOUR PENALTY IF:
-YOU WROTE TO IRS AND ASKED FOR ADVICE ON A SPECIFIC ISSUE,
-YOU GAVE IRS COMPLETE AND ACCURATE INFORMATION,
-IRS WROTE BACK TO YOU AND GAVE YOU A SPECIFIC COURSE OF
ACTION TO TAKE OR EXPLAINED WHAT ACTIONS NOT TO TAKE,
-YOU FOLLOWED OUR WRITTEN ADVICE IN THE MANNER WE OUTLINED, AND
-YOU WERE PENALIZED FOR THE WRITTEN ADVICE WE GAVE YOU.
TO HAVE THE PENALTY REMOVED BECAUSE OF ERRONEOUS WRITTEN ADVICE FROM IRS,
YOU SHOULD:
-COMPLETE FORH 845, CLAIH FOR REFUND AND REQUEST FOR ABATEMENT,
-REQUEST THAT IRS REMOVE THE PENALTY, AND
-SEND FORM 845 TO THE IRS SERVICE CENTER WHERE YOU FILED YOUR
RETURN FOR THE YEAR YOU RELIED ON ERRONEOUS ADVICE FROM THE IRS.
THE THREE DOCUMENTS YOU MUST ATTACH TO YOUR FORH 843 ARE=
-A COPY OF YOUR ORIGINAL REQUEST FOR ADVICE FROM IRS,
-A COPY OF THE ERRONEOUS WRITTEN ADVICE FROM IRS, AND
-A NOTICE (IF ANY) SHOWING THE PENALTY WE CHARGED THAT
YOU NOW WISH US TO REHOVE.
HELPFUL HINT: FOR FASTER SERVICE, TRY CALLING US ANY DAY EXCEPT MONDAY WHEN OUR
CALL VOLUMES ARE HIGHEST.
RFTI.:II~N TI-IT~; PAgT TI'I I1~ ~4TTH vnl~R t'-14~=t"l~' np TN~I~IDY
BUREAU OF /NDZVZDUAL TAXES
DEPT. 280~$1
HARR/SBURG, PA 1712B-Oq51
COMMONNEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
ALBERT RABENA
110 SUNRISE AVENUE
NEN CUMBERLND
PA 17070
BTLL'rNG NOTICE
DATE OF NOTICE: JUL 18 2003
SOCIAL SEC. MUM: 172-01-0352
TAX YEAR: 2002
ASSESSMENT:
BALANCE(S) DUE FOR YOUR ACCOUNT AS OF JUL 28 2005
~ BALANCE INCLUDES ESTZHATED TAX UHDERPAYHENT PENALTY
O#ED PA/D BALANCE
L PEN/ADD 18.40 .00 18.40
EST PNLTY 12.14 .00 12.14
LEGAL .00 .00 .00
INTEREST 1.$6 .00 1.56
TAX/RFD 568.00 568.00 .00
PLUS OTHER TAX YEAR(S) LIABZL/TZES C~E
TOTAL DUE
PLEASE PAY THIS AMOUNT USING THE DETACHABLE LOW
YOUR 2002 TAX RETURN NAS PROCESSED AS FOLLONS. YOUR FIGURES
.00
lA. GROSS COMPENSATION .......................... .00
lB. SCHEDULE UE EXPENSES ........................ .00
1C. COMPENSATION ................................ 725.00
2. INTEREST (SCHEDULE A) ....................... 456.00
5. DIV/DENDS (SCHEDULE B) ...................... ~48.00-
4. NET INCOME OR LOSS ..........................
$. TAXABLE SALE - GAIN OR LOSS ................. 11,979.00
SA. CAPITAL GAIN EXCLUSION ...................... .00
6. RENTS, ROYALTIES, PATENTS, COPYRIGHTS ........ O0
7. ESTATES AND TRUSTS (SCHEDULE J) .............. O0
8. GAMBLZN~ AND LOTTERY NINNINGS ............... .00
9. GROSS TAXABLE INCOHE (ADD LINES 1C,2-5,6-8). 15,160.00
10. CONTRIBUTIONS TO NED/CAL SAVINGS ............ .00
11. NET PA TAXABLE INCOME(LINE 9 HINUS LINE 10). 15,160.00
12. TAX LIAB/LITY (HULTIPLY LINE 11 DY .02800).. 568.00
15. TAX #ITHHELD (FROH W2'S) .................... .00
14. CREDIT FROH PREVIOUS TAX YEAR ................ O0
15&16 ESTIMATED TAX S EXTENSION PAYHENTS .......... .00
17. TAX WITHHELD AS REPORTED ON NRK-1 ............ O0
18. TOTAL CREDITS (ADD LINES 14-17) ............. .00
0
19B. NUHBER OF DEPENDENTS ........................ .00
21. TAX FORGIVENESS CREDIT ......................
22. RESIDENT CREDIT (SCHEDULE G) ................ .00
.00
25. CREDITS (SCHEDULE OC) .......................
24. TOTAL CRED/TS (ADD LINES 15,18,21-25) ...... .00
IS. TAX DUE (LINE 12 MINUS 24) .................. 568.00
26. PENALTIES AND INTEREST ....................... O0
28. OVERPAYMENT (LINE 24 HINUS 12) ............... O0
.00
29. REFUNDED ....................................
50. CREDITED TO NEXT YEARS ESTIHATED TAX ......... O0
51-$5.TOTAL DONATIONS (LINES 51-55) ............ .00
OUR FIGURES
.00
.00
.00
7?_6.00
q56.00
448.00-
11,979.00
.00
.00
.00
.00
15,160.00
.BO
15,160.00
.00
.00
.00
.00
.00
0
.00
.00
.00
.00
568.00
.00
.00
.00
.00
SEE REVERSE SIDE FOR MORE INFORMATION
DETACH AT PERFORATION
I_l~.. ~ BlueCross ® 1
m~+ ~!~+ BlueShield~ Explanation of Benefits
Federal
Employee
Program
THIS IS NoT A BILL
169
www. fepblue.org
Camp Hill, Pem~ylvama 17089
PENNSYLVANIA BLUE SHIELD
PO BOX 890037 CAMP HILL PA 17089-0037
ALBERT RABENA
THE WOODS
824 LISBURN RD
CAMP HILL PA 17011-7102
MEDICAL QUESTIONS CALL 1-800-779-6945,
DENTAL QUESTIONS CALL 1-800-746-5687,
TTY QUESTIONS CALL 1-800-345-3848
EXPLANATION OP BENEFITS AT A GLANCE
Benefit Check Enclosed
Patient Name:
Dates of Service:
You Owe the Provider:
ALBERT RABF~A
02/03/2003 - 02/03/20Q~
S45,97
ID Number: R00782203
Claim Number: 03593615773
Claim Paid On: 04/04/2003
Claim Received On: 04/02/2003
Claim Processed On: 04/04/2003
CHECK NUMBER: 51897734
Provider: LOWERALLENTOWNSHIP Dates of Service: 02/03/2003 - 02/03/2003
Type: NON-PARTICIPATING PROVIDER
Type of Service
AMBULANCE SERVICES
AMBULANCE SERVICES
AMBULANCE SERVICES
Submitted ] Plan IRemarkl DeductlCoinsurancel ~edicare/
Charaas ! Allowance ! Codes! ! Or CoDer !Other Ins.
35o.ool 21o.891 303 I I 168.711
s s 31o i i i
19.50) 12.421 303 I [ 9.94l
I I 310 I i i
46.001 6.561 303 I I 5.251
i i 31o i i I
What ]You Owe the
Wa Paid ) Provider
42.181 42.18
I
Z.48) 2.48
I
1.311 1.31
TOTALS:
$415.50)
S229.87! ) ~0.00! $0.001 ~;183.90!
EXPLANATION OF REMARK CODES
S45.97! $45.97
303--YOUR HEALTH CARE PROVIDER HAS AGREED ~ ACCEPT ASSIGNMENT OF MEDICARE
BENEFITS~THISt~EANS¥OU-ARE NOT RESPONSIBLE FOR THE DIFFERENCE BETWEEN THE
MEDICARE - APPROVED AMOUNT AND THE ACTUAL CHARGE.
310--YOU ARE ENROIJ_ED IN MEDICARE, WHICH IS PRIMARY. THIS MEANS MEDICARE PROVIDES
BENEFITS FIRST. WE HAVE PAID 100% OF THE ALLOWABLE CHARGES ON THIS CLAIM
AFTER MEDICARE'S PAYMENT. NO DEDUCTIBLE OR COINSURANCE APPLIES.
YOUR RESPONSIBILITY TO THE PROVIDER(S) IS $45.97. WE PAID $45.97.
THE PROVIDER CAN COLLECT $45.97 FROM YOU FOR THESE SERVICES.
BlueShield.
Federal Employee Program
www. fepblue.org
Camp Hill, Pennsylvama 17089
Explanation of Benefits
179
THIS IS NOT A BILL
PENNSYLVANIA BLUE SHIELD
PO BOX 890037 CAMP HILL PA 17089-0037
ALBERT RABENA
824 LISBURN RD APT 619
CAMP HILL PA 17011-7101
MEDICAL QUESTIONS CALL 1=800-779-6945,
DENTAL QUESTIONS CALL 1-800-746-5687,
TTY QUESTIONS CALL 1-800-345-3848
EXPLANATION OF BENEFITS AT A GLANCE
I
IBenefit Check Enclosed
IPatient Name:
I
IDates of Service:
IYou Owe the Prgv~er:
ALBERT RABENA
02/20/2003 - 02/20/2003
ID Number: R00782203
Claim Number: 03614615725
Claim Paid On: 04/25/2003
Claim Received On: 04/23/2003
Claim Processed On: 04/25/2003
CHECK NUMBER: 51904710
Provider~ SILVERSPRINGAMBULANCEANDRESCUE Dates of Service: 02/20/2003 - 02/20/2003
Type: NON-PARTICIPATING PROVIDER
Type of Service I Submitted I Plan IRemarkl Deduct~CoinsuranceI Medicare/ ~ What I~ou Owe the
! Charaes ! Allowance ! Codes! ! Or CoDav !Othec Ins. ! We Paid ! Provider
I 300.001 171.571 303 I I I 137.26l 34.311 34.31
t I I 310 I I I I I
i 45,OOl Z7.35) 303I I I 21.881 5.471 5.47
i i ) 310 i i ) i i
} S345.00) S198.92{ } S0.00! S0.00} S159.14) 839.78
EXPLANATION OF REMARK CODES
303--YOUR HEALTH CARE PROVIDER HAS AGREED l~D ACCEPT ASSIGNMENT OF MEDICARE
BENEFITS. THIS MEANS YOU ARE NOT RESPONSIBLE FOR THE DIFFERENCE BETWEEN THE
MEDICARE - APPROVED AMOUNT AND THE ACTUAL CHARGE.
310--YOU ARE ENROLLED IN MEDICARE, WHICH IS PRIMARY. THIS MEANS MEDICARE PROVIDES
BENEFITS FIRST. WE HAVE PAID 100% OF THE ALLOWABLE CHARGES ON THIS CLAIM
AFTER MEDICARE'S PAYMENT. NO DEDUCTIBLE OR COINSURANCE APPLIES.
YOUR RESPONSIBILITY TO THE PROVIDER(S) IS $39.78. WE PAID $39.78.
THE PROVIDER CAN COLLECT $39.78 FROM YOU FOR THESE SERVICES.
THE SERVICE BENEFIT PLAN OFFERS HEALTH CARE INFORMATION SERVICES 24 HOURS A
DAY, 7 DAYS A WEEK. CALL BLUE HEALTH CONNECTION, TOLL-FREE AT 1-888-BLUE-432
.(1-888-258-3432). WITH BLUE HEALTH CONNECTION, YOU HAVE ACCESS TO REGISTERED
NURSES WHO CAN HELP YOU ASSESS YOUR SYMPTOMS. USING BLUE HEALTH CONNECTION
MAY SAVE YOU TIME AND UNNECESSARY OUT-OF-POCKET EXPENSES. YOU CAN ALSO
ACCESS OTHER HEALTH RESOURCES ONLINE AT WWW.FEPBLUE.ORG
AMBULANCE SERVICES
AMBULANCE SERVICES
TOTALS:
$39.78!
ALERT PHARMACY SERV.,INC.219 NORTH BALTIMORE AVE. MT.HOLLY SPRINGS,PA 17065
YTD FIN NON- LEGEND
CHARGE FOR MONTH
AMOUNT DUE
/
FORMEX 717-533-1230 www.formexinc.com
REV-15~13 EX + (9-00)) ~
COMMONVVEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF RABENA, ALBERT FILE NUMBER 21-03-0330
RELATIONSHIP TO DECEDENT AMOU~TCR
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) ~
OFESTA3E
II.
1
2
3.
4.
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and
transfers under Sec. 9116 (a) (1.2)]
Jacqueline M. Ball
:{onald A. Rabena
;)avid A. Ball
Nell D. Bali
Daughter
Son
Grandson
Grandson
50%
50%
$1,000.00
$1,000.00
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON UNES 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
New Cumberland Fireman
$1,000.00
TOTAL OF PART ]] - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
$1,000.00
(If more space is needed, insert additional sheets of the same size)
B2xRB2KRA SUMPLE - SULLIV_&N
ATTORNEY AT LAW
~49 BRIDG£ STRE:ET
NEW CUMBERLAND, PENNSYLVANIA 17070-1931
Register of Wills
Cumberland County Courthouse
1 Courthouse Square
Carlisle, PA 17013
TO
Law Offices of
BARBARA SUI tPLE-SULLIVAN
549 Bridge Street
New Cumberland, PA 17070-1931
Register of Wills
Cumberland County Courthouse
1 Courthouse Square
Carlisle, PA 17013
U.S. P0~
,- PR1D
RMOUNT NEN ~UHBERL~
[7070
,,osr,~L s~,v,c~ , 17013
0O00
Name of Decedent:
Date of Death:
Will No.
STATUS REPORT UNDER RULE 6.12
PAULINE R. SCHELL
February 22, 2003
2003-00330
Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rule, I report the
following with respect to completion of the administration of the above-captioned estate:
1. State whether administration of the Estate is complete:
Yes 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:
a. Did the personal representative file a final account with the Court?
Yes No X
b. The separate Orphans' Court No. (if any) for the personal
representative's Account is:
Co
parties of interest?
Did the personal representative state an account informally to the
Yes X No
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: January 30, 2004 ~~ff"~~ EDMUND G. MYERS
JOHNSON, DUFFIE, STEWART & WEII)NER
301 Market Street
P.O. Box 109
Lemoyne, PA 17043
(717) 761-4540
Capacity: ~Personal Representative
(x) Counsel for Personal
Representative
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 180601
HARRISBURG, PA 17118-0601
BAR~ARA SUHPLESULLIVAN ES
549 BRIDGE ST
NEW CUHBERLAND PA 171~0
- ' ...... d PA
COHHONWEALTH OF PENNSYLVANIA
DEPARTHENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAZSENENT, ALLO#ANCE OR DZSALLO#ANCE
OF DEDUCTTONS AND ASSESSNENT OF TAX
, :-~ ESTATE OF
DATE OF DEATH
"~ [EB 13 ~3:31COUNTyFZLE NUH~ER
ACH
CUT ALONG THZS LINE ~
02-09-2004
RABENA
03-08-2005
21 05-0550
CUHBERLAND
101
Amoun't Rem i'l:'l:ed
REV-15~7 EX &FP Cffl-OS)
ALBERT
HAKE CHECK PAYABLE AND REHZT PAYHENT TO:
REGISTER OF WILLS
CUHBERLAND CO COURT HOUSE
CARLISLE, PA 17015
RETAIN LOWER PORT/ON FOR YOUR RECORDS ~
REV-1547 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAZSENENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSHENT OF TAX
ESTATE OF RABENA ALBERT FZLE NO. 21 03-0330 ACN 101 DATE 02-09-2004
TAX RETURN NAS: { ) ACCEPTED AS FZLED (X) CHANEED SEE ATTACHED NOTICE
RESERVATZON CONCERNZNG FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Es~a~a (Schedul~ A)
S*ocks and Bonds (Schedule B)
$ Closely Held S*ock/Par~nership Interest (Schedule C)
Hor~gages/No~as Raca/vable (Schedule D)
$ Cash/Bank Deposi~s/Nisc. Personal Proper*y (Schedule E)
6 Jointly O~ned Proper*y (Schedule F)
7 Transfers (Schedul~ G)
8 Total Asse~s
APPROVED DEDUCT/ONS AND EXEHPTZONS:
9. Funeral Expenses/Adm. Cos~s/Nisc. Expanses (Schedule H)
10. Debts/Norigaga Liabilities/Liens (Schedule I)
11. Total Deductions
12. Ne~ Value of Tax Re*urn
(1) O0
(2)
($)
(~)
(5)
(6)
(7)
151~979 50
O0
25~457.50
6~295.75
Z6~ZIZ 82
O0
(8)
(9)
10,692.58
(10}
4,164.82
(11)
(1P)
15.
1~,.
NOTE:
Charitable/Governmental Bequests; Non-elected 9115 Trusts (Schedule J) (15)
Ne~ Value of Estate Sub~ec~ ~o Tax
If an assess.ent Nas issued previously, 11nee lI, 15 and/or 16, 17,
reflect figures that include the total of ALL returns assessed to date.
NOTE: To insure proper
credi~ *o your account,
submi~ ~he upper portion
of *hAs fore wi~h your
~ax payment.
207,925.57
ASSESSHENT OF TAX:
15. A.oun~ of Line 1~ a* Spousal ra~e
16. Amoun~ of Line 1~ taxable a~ Lineal/Class A ra~e
17. Aeoun~ of Line 1~ a~ Sibling ra~e
16. Aeoun~ of Line 1~ ~axablo a~ Collateral/Class B ra~e
19. Principal Tax Due
TAX CREDITS:
PAYHENT KECEZPT DISCOUNT
DATE NUHBER INTEREST/PEN PAID (-)
06-05-Z00~ CD001654 $94.74
12-05-2005 CD005515 .00
1~.857.~0
193,068.17
1,000.00
192,068.17
18 and 19 will
(15), .00 X O0 = .00
(16). 192,068.17 X 045= 8,645.06
(17) .00 x 12 : .00
(18) .00 x 15 = .00
(19)= 8,643.06
ZF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
ANOUNT PAID
7,500.00
768.06
TOTAL TAX CREDIT
BALANCE OF TAX DUE
ZNTEREST AND PEN.
TOTAL DUE
8,662.80
19.74CR
.00
19.74CR
( IF TOTAL DUE TS LESS THAN $1, NO PAYHENT IS RE~UTRED.
ZF TOTAL DUE IS REFLECTED AS A 'CREDZT' (CR), YOU NAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.)
RESERVATION:
PURPOSE OF
NOTICE:
PAYMENT:
REFUND (CA):
OBJECTIONS:
ADMZN-
LSTRATIVE
CORRECTIONS:
DISCOUNT:
PENALTY:
INTEREST:
Estates of decedents dying on or before December ZZ, 1982 -- if any future interest in the estate is transferred
in possession or enjoyment to Class B (collateral) beneficiaries of the decedent after the expiration of any estate for
life or for years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes
at the lawful Class B (collateral} rate on any such futura interest.
To ~ulfi11 the requirements of Section glqO of the Inheritance and Estate Tax Act, Act g$ of 2000. (72 P.S.
Section 91qO).
Detach the top portion of this Notice and submit with your payment to the Register of NiIls printed on the reverse side.
--Make check or money order payable to: REGISTER OF HILLS, AGENT
A refund of a tax credit, which was not requested on the Tax Return, may be requested by completing an "Application
for Refund of Pennsylvania Inheritance and Estate Tax" (REV-151S). Applications ara available at the Office
of the Register of Hills, any of the 23 Revenue District Offices, or by calling the special Iq-hour
ansaering service for forms ordering: 1-800-$6Z-ZOSO; services for taxpayers with special hearing and / or
speaking needs: 1-800-~47-3020 (TT 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 (60) days of receipt of
this Notice by:
--#ritten protest to the PA Department of Revenue, Board of Appeals, Dept. Z81OZ1, Harrisburg, PA 17ILS-lOLl, 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 ba addressed in writing to: PA Department of Revenue,
Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, Dept. Z80601, Harrisburg, PA 171Z8-060!
Phone (7[7) 787-650S. Sam page S of the book[et "Instructions for Inheritance Tax Return for a Resident
Decedent" (REV-IS01) for an explanation of administratively correctable errors.
If any tax due is paid within three (3) calendar months after the dacedent's death, a five percent (5Z) discount of
the tax paid is allowed.
The 1SI tax amnesty non-participation penalty is computed on the total of tho tax and interest assessed, and not
paid before January 18, 1996, the first day after the and of the tax amnesty period. This non-participation
penalty is appealable in the same manner and in the the same tiaa 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 deIinquent before January 1, 1982 bear interest at the rate of
six (6Z) percent per annum calculated at a daily rate of .000166. All taxes which became delinquent on and after
January 1, 198Z will bear interest at a rate ahich ail1 vary from calendar year to calendar year with that rate
announced by the PA Dapar~ent of Revenue. The applicable interest rates for 1982 through ZOO3 are:
Interest Daily Interest Daily Interest Daily
Year Rate Factor Year Rate Factor Year Rate Factor
I982 207. , 000566 1987 97. . 000267 1999 77. . 000192
1983 16Z .000638 1988-1991 llZ .000301 2000 82 .000Z19
1986 11Z . 000301 1992 9Z . 000Z67 ZOO1 9Z . 000267
1985 132 .000356 1995-1996 7X .O0019Z 200Z 6Z .000166
1986 lOX . 000276 1995-1998 92 . 000267 2003 52 . 000157
--Interest is calculated as follows:
TNTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELTNI;IUENT X DAILY INTEREST FACTOR
--Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (15) 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.
REV-14~O EX {8-88)
.~ INHERITANCE TAX
EXPLANATION
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE OF CHANGES
BUREAU OF INDIVIDUAL TAXES
DEPT, 280601
HARRISBURG, PA 17128-0601
DECEDENT'S NAME FILE NUMBER
Albert Rabena 2103-0330
REVIE-VVED BY ACN
ANITA MCCULLY 101
ITEM
SCHEDULE NO. EXPLANATION OF CHANGES
The value of this item has been suspended from the appraisement of the return until the
E 3
final value can be determined. A supplemental return must be filed when the value of the
suspended item is determined.
ROW Page 1
BARBARA SUMPLE- SULLIVAN
Register of Wills
Cumberland County Courthouse
1 Courthouse Square
Carlisle, PA 17013
170i~+~2~ 02 i"'llh,,lll,-,-th,th. Ih,,Ih,, hh,lh h h,hh,hh,i
LAW OFFICES
BARBARA SUMPLE- SULLIVAN
NEW CUMBERLAND, PENNSYLVANIA 170~;153i ~ *
'04 OCT 14 ?i2:t8
October 13, 2004
Register of Wills
Cumberland County Courthouse
1 Courthouse Square
Carlisle, PA 17013
Re: Estate of Albert Rabena
No. 21-03-0330 / Cumberland County
Dear Sir/Madam:
Pursuant to your Notice of Inheritance Tax dated September 9, 2004, enclosed please
fred Check No. 1010 in the amount of $2,197.65 for payment of the additional tax due on the
above referenced Estate.
Should you have any questions please contact my office.
Barbara Sumple-Sullivan
BSS/ld
Enclosures
cc: Ms. Jacqueline R. Ball, Executrix
r-~JREAU OF INDIVtDUAL TAXES
INHERITANCE TAX DIVI*~IO N
DEPT. 280601
HARRISBURG, Ic i7128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
DATE .. 09-06-2004
~-~ ~ ' ESTATE OF RABENA
r~ DATE O~OEATH 03-08-2003
BARBARA SUMPLE-SULUVAN ESQ
549 BRIDGE ST
NEW CUMBERLAND PA 17070
ALBERT
FILE NO. 21 03-0330
COUNTY Cumberland
ooTA~ ~ :18 101
Amount Remitted I
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
Reglstar of Wills
Cumberland County CourUtouse
Carlisle, PA 17013
CUT ALONG THIS LINE c~ RETAIN LOWER PORTION FOR YOUR RECORDS
REV-1547 EX (06-97) PC NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF RABENA ALBERT FILE NO. 21 03-0330 ACN 10t DATE 09-06-2004
TAX ~t:¥URN WAS: ( [] ) ACCEPTED AS FILED ( [] ) CHANGED SEE ATTACHED NOTICE
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: SUPPLEMENTAL 01 RETURN
1. Real Estata (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Stock/Partr~ersh!p Interest (Schedule C) (3)
4. Mortgages/Notes Receivable (Schedule D) (4)
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5)
6. Jointly Owned Property (Schedule F) (6)
7. Transfem (Schedule G) (7)
8. Total Assets
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9)
10. Debts/Mortgage Liabilities/Liens (Schedule I) (10)
11. Total Deductions
12. Net Value of Tax Retum
13. Charitabls/Govemmental Bequests; Non-elected 9113 Trusts (Schedule J)
0.00 NOTE: To Insure proper
0.00 credit to your account,
0.00 submit the upper portion
0.00 of this form with your
48,250;00 tax payment.
0.00
0.00
(8)
0.00
0,00
48,250.00
(11) 0.00
(12) 48~250.00
(13) 0.00
14.
NOTE:
Net Value of Estate Subject to Tax (14) 240,318.17
If an assessment was issued previously, lines 14, 15 end/or f6, 17 and t8 will reflect figures
that include the total of ALL returns assessed to date.
(15) 0.00 X .00 0.00
(16) 240~318.17 X .045 10~814.31
(17) 0.00 X .12 0.00
(18) 0.00 X .15 0.00
(19) 10,814.31
ASSESSMENT OF TAX:
15. Amount of Line 14 at Spousal rate
16. Amount ofLine 14 taxable at Lineal/ClassArate
17. Amount of Line 14 taxable at Sibling rata
18. Amount of Wne 14 taxable at Collateral/Class B rate
19. Principal Tax Due
TAX CREDITS:
PAYMENT REucu.' ! DISCOUNT (+)
DATE NUMBER INTEREST/PEN PAJD (-) AMOUNT PAID
06-05-2003 CD002654 394.74 7,500.00
12-05-2003 CD003315 0.00 768.06
03-10-2004 WRITEOFF 0.00 23.34
INTEREST IS CHARGED THROUGH 09-21-2004 TOTAL TAX CREDIT 8,662.80
AT THE RATES APPLICABLE AS OUTLINED ON THE BALAN CE OF TAX DUE 2,151.51
REVERSE SIDE OF THIS FORM INTEREST 46.14
TOTAL DUE 2,197.65
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVlOUAL TAXES
DEPT 280601
HARRISE~URG, PA 17128-0601
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
REV 1162 EX(11 96)
NO. CD 004493
SUMPLE-SULLIVAN BARBARA
549 BRIDGE STREET
NEW CUMBERLAND, PA 17070
ESTATE INFORMATION: SSN: 172-0~-0352
FILE NUMBER: 2103-0330
DECEDENT NAME: RABENA ALBERT
DATE OF PAYMENT: 10/14/2004
POSTMARK DATE: 10/13/2004
COUNTY: CUMBERLAND
DATE OF DEATH: 03/08/2003
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 82,197.65
REMARKS:
TOTAL AMOUNT PAID:
$2,197.65
SEAL
CHECK# 1010
INITIALS: JA
RECEIVED BY:
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
BARBARA SUMPLE-SULLIVAN ESQ
549 BRIDGE ST
NEW CUMBERLAND PA 17070
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
DATE 09-06-2004
ESTATE OF RABENA
DATE OF DEATH 03-08-2003
FILE NO. 21 034)330
COUNTY CumbeHand
ACN 10t
Amount Remitted
REV-la4? EX (t2-117) PC
ALBERT
CUT ALONG THIS LINE
REV-1~7EX(06-97)PC
ESTATE OF RABENA
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
Register of Wills
Cumberland County Courthouse
Carlisle, PA 17013
..c:~_ RETAIN LOWER PORTION FOR YOUR RECORD~["~
NOTICE (~ 'l~i ~'1~ I~1"1;~,~ ~-~[' ;1'~. j(' X ~'i5 I~'~j~IEi~:-I~;I':'.~.'~L~/,~ji~I~' ~'- ~ ........ ~-'-~ '- ................
DI ' .......
SALLOWANCE OF DEDUCTIONS AND ASSESSMENT OI~£~'AX
ALBERT FILE NO. 21 03-0330 ACH. 101 cm DATE 09.06-2004
TAX RETURN WAS:
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: SUPPLEMENTAL 01 RETURN
( [] ) ACCEPTED AS Fl/F_n
([])CHANGED
SEE~TTACHED'NOTICE
Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J)
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interest (Schedule C)
4. Mortgages/Notes Receivable (Schedule D)
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13.
(1) 0.00 ['~ NO ~.TIE: To Insure proper
(2) ::,, ,, ~ . 0.00 <_,J credit tO'your account,
(3) 0.00 ~ submit the upper portion
(4) 0.00 of this form with your
(5) 48,250.00 tax payment.
(6) 0.00
(7) 0.00
(8) 48,250.00
(9) 0.00
(10) 0.00
(11) 0.00
(12) 48,250.00
(13) 0.00
14.
NOTE:
that Include the total of ALL returns assessed to date.
Net Value of Estate Subject to Tax (14) 240,318.17
If an assessment was issued previously, lines 14, 15 and/or 16, 17 and 18 will reflect figures
ASSESSMENT OF TAX:
15. Amount of Line 14 at Spousal rate (15) 0.00 X .00 0.00
16. Amount of Line 14 taxable at Lineal/Class A rate (16) 240,318.17 X .045 10,814.31
17. Amount of Line 14 taxable at Sibling rate (17) 0.00 X .12 0.00
18. Amount of Line 14 taxable at Collateral/Class B rate (18) 0.00 X .15 0.00
19. Principal Tax Due
TAX CREDITS: (19) 10,814.31
PAYMENT RECEIPT DISCOUNT (+)
DATE NUMBER INTEREST/PEN PAID (-) AMOUNT PAID
06-05-2003 C D002654 394.74 7,500.00
12-05-2003 C D003315 0.00 768.06
03-10-2004 WRITEOFF 0.00 23.34
INTEREST IS CHARGED THROUGH 09-21-2004 TOTAL TAX CREDIT 8,662.80
AT THE RATES APPLICABLE AS OUTLINED ON THE BALANCE OF TAX DUE 2,151.51
REVERSE SIDE OF THIS FORM INTEREST 46.14
TOTAL DUE 2,197.65
* 'rF PAID AFTER DATE ZND'rCATED, SEE REVEP. SE rT~'
FOR CALCULATZON OF ADDZTZON~L ZNTEP. EST.
LESS THAN $1, NO PAI'M~NT IS REQUZRED.
IF TOTAL DUE ZS P. EFLECT~D AS A CREDIT (CR), YOU MAY BE DUE
A REI~]ND. SEE REVERSE SIDE OF THIS FOP~ FOR INSTRUCTIONS. )
RESERVATION:
PURPOSE OF
NOTICE:
PAYMENT:
REFUND (CR):
OBJECTIONS:
ADMINISTRATIVE
CORRECTIONS:
DISCOUNT:
PENALTY:
INTEREST:
Estates of decedents dying on or before December 12, 1982 - if any future interest in the estate is transferred in possession or enjoyment to Class B
(collateral) beneficiaries of the decedent after the expiration of any estate for life or for years, the Commonwealth hereby expressly reserves the dght to
appraise and assess transfer Inheritance Taxes at the lawful Class B (collateral) rate on any such future interest.
To fulfill the requirements of Section 2140 of the Inheritance and Estate Tax Act, Act 21 of 1995. (72 P.S. Section 9140).
Detach the top portion of this Notice and submit with your payment to the Register of Wills pdnted on the reverse side. Make check or money order
payable to: REGISTER OF WILLS; AGENT.
A refund of a tax credit, which was not requested on the Tax Return, may be requested by completing an "Application for Refund of Pennsylvania
Inheritance and Estate Tax (REV-1313). Applications are available at the Office of the Register of Wills or any of the 23 Revenue District Offices, or by
calling the special 24-hour answering service numbers for forms ordering: In Pennsylvania 1-800-362-2050, outside Pennsylvania and within local
Harrisburg area (717) 787-8094, TDD~ (717) 772-2252 (Hearing Impaired Only).
Any party in interest not satisfied with the appraisement, allowance or disellowance of deductions, or assessment of tax (including discount or interest) as
shown on this Notice must object within sixty (60) days of receipt of this Notice by:
--written protest to the PA Department of Revenue Board of Appaals, 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. 280601 Harrisburg, PA 17128-0601 Phone (717) 787-6505. See page 3 of the booklet "instructions for Inheritance Tax
Return for a Resident Decedent" (REV-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 (5%) discount of the tax paid is allowed.
The 15% tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not paid before
January 18,1996, the first day after the end of the tax amnesty period. This non-participabon penalty is appealable in the same manner and in 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 delinquent before January 1, 1982 bear interest at the rate of six (6%) percent par annum calculated at a daily rate of .000164. All taxes
which became delinquent on and after January 1, 1982 will bear interest at a rate which will vary from calendar year to calendar year with that rate
announced by the PA Department of Revenue. The applicable interest rates for 1982 through 2001 are:
Interest Daily Interest Daily
Year Rate Factor Year Rate Factor
1982 20% .000548 1988-1991 11% .000301
1983 16% .000438 1992 9% .000247
1984 11% .000301 1993-1994 7% .000192
1985 13% .000356 1995-1998 9% .000247
1986 10% .000274 1999 7% .000192
1987 9% .000247 2000 8% .000219
Interest Daily
Year Rate Factor
2001 9% .000247
2002 6% .000164
2003 5% .000137
2004 4% .000110
--Interest is calculated as follows:
INTEREST = BALANCE OF TAX UNPAID X NUMBER OF DAYS DELINQUENT X DALLY INTEREST FACTOR
*-Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (15) 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.
REV-1470 EX (6-88)
INHERITANCE TAX
COMMONVVEALTH OF PENNSYLVANIA EXPLANATION
DEPARTMENT OF REVENUE OF CHANGES
BUREAU OF INDIVIDUAL TAXES
DEPT, 280601
HARRISBURG, PA 17128-0601
DECEDENI~S NAME FILE NUMBER
Albert Rabena 2103-0330
REVIEWED BY
ANITA MCCULLY ACN
101
ITEM
SCHEDULE NO. EXPLANATION OF CHANGES
E The amount of the bequest has been reduced from $56,250.00 to $48,250.00. This
reduction represents the amount received after the inheritance tax payment was made to
the Estate of Theodore A. Rabena.
Interest is abated in the amount of $23.34 from the delinquent date 12-08-03 to 03-10-04,
the date of receipt of the proceeds of litigation.
Interest is effective 03-11-04.
Lineal heirs are taxable at the rate of 4.5% for dates of death on or after 07-01-2000.
The credit listed as paid from the Theodore A. Rabena Estate is not a payment in this
estate. Tax remains due.
ROW Page 1
BUREAU OF INDIVIDUAL TAXES
TNHERTTANCE TAX DTV/STON
PO BOX Z80601
HARRISBURG,, PA 171Z8-0601
BARBARA SUNPLESULLIVA S
5q9 BRIDGE ST
NEW CUMBERLAND PA !,7.070
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
ZNHERZTANCE TAX
STATEMENT OF ACCOUNT
DATE 11-Z9-ZOOq
ESTATE OF RABENA
DATE OF DEATH 05-08-2005
FILE NUMBER 21 03-0330
COUNTY CUMBERLAND
ACN 101
REV-~,6O? EX AFP
ALBERT
Amoun'l: Rem'~ ~*ed I
HAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17015
NOTE: To insure proper credi~ ~o your account, submi~ ~he upper portion of ~his form wi~h your ~ax payment.
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS
ESTATE OF RABENA
ALBERT
FILE N0.21 05-0550 ACN 101
DATE 11-29-200~
THIS STATEMENT 1S PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAHED ESTATE. SHONN BELON
ZSA SUHHARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, ZF APPLICABLE,
A PROJECTED INTEREST FIGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 05-31-200~
PRINCIPAL TAX DUE:.
PAYMENTS (TAX CREDITS):
10,81q.51
PAYMENT RECEIPT DISCOUNT (+)
DATE NUMBER INTEREST/PEN PAID (-) AMOUNT PAID
06-05-2005
12-05-2005
03-10-200q
10-15-200q
CDOOZ65R
CD005515
WRITEOFF
CDOO~q9$
.00
.00
q6.1q-
7,500.00
768.06
23.3~
2,197.65
BALANCE OF UNPAID INTEREST/PENALTY AS OF lO-lq-ZOOq
ZF PAID AFTER THIS DATE, SEE REVERSE
SIDE FOR CALCULATION OF ADDITIONAL INTEREST.
ZF TOTAL DUE ZS LESS THAN $1,
NO PAYHENT ZS REQUIRED.
ZF TOTAL DUE ZS REFLECTED AS A "CREDZT"
TOTAL TAX CRED'rT
10,81q.$1
.00
BALANCE OF TAX DUE
INTEREST AND PEN. 5.23
TOTAL DUE 5.23
YOU NAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR zNSTRUCT/ONS.
PAYMENT:
Detach the top portion of this Notice and submit with your payment made payable to the name and address
printed an the reverse side.
-- If RESIDENT DECEDENT make check or money order payable to: REGISTER OF NILLS) AGENT.
-- If NON-RESIDENT DECEDENT make check or money order payable to: COMMONNEALTN OF PENNSYLVANIA.
REFUND (CA): A refund of a tax credit, which ems not requested on the Tax Return) may be requested by completing an
"Application for Refund of Pennsylvania Inheritance and Estate Tax" (REV-IS13). Applications ars available
online at www.ravenus.state.pa.us, any Register of Mills or Revenue District Office, or from the Department's
Z4-hour answering service for forms orders: 1-BOO-36Z-Z050; services for taxpayers with speclal hearing and/or
speaking needs: 1-BOO-447-30ZO (TT only).
REPLY TO:
DISCOUNT:
PENALTY:
questions regarding errors contained on this notice should be addressed to: PA Department of Revenue) Bureau
of Individual Taxes, ATTN: Post Assessment Review Unit, P.D. Box ZB060i, Harrisburg, PA 171ZB-0601, phone
(717) 787-6505.
If any tax due is paid within three (3} calendar months after the docedent's death, a five percent CSX) discount
of the tax paid is allowed.
The iSX tax amnesty non-participation penalty is computed on the total of the tax and interest assessed) and not
paid before January l&~ i996) the first day after the end of the tax amnesty period.
INTEREST:
Intsrest is charged beginning with first day of delinquency, or nine (9) months and one (I) day from the date of
death, to the date of payment. Taxes which became delinquent before January l~ lgBz bear interest at the rate of
six (6Z) percent per annum caLcuLated at a daily rate of .000164. Al1 taxes which became delinquent on and after
January l~ lgBZ wiiI bear interest at a rate which will vary from calendar year to calendar year with that rata
announced by the PA Department of Revenue. The applicable interest rates for 198Z through ZOO4 are:
Interest Daily Interest Daily Interest Daily
Year Rata Factor Year Rate Factor --Year Rate Factor
198Z ZOZ .00054B L98B-1991 11Z .000301 ZOO1 9Z .000Z47
1983 16Z .000438 199Z 9Z .000247 2002 6Z .000164
198q 11Z .000301 1993-1994 7Z .00019Z 2003 SZ .000137
1985 13Z .000356 1995-1998 9Z .O00Zq7 ZOO4 ~Z .000110
1986 IOZ .O00Z7q 1999 7Z .O0019Z
1987 9Z .000Z47 2000 8Z .000Z19
--Interest is calculated as follows:
TNTEREST = BALANCE OF TAX UNPATD X NUNBBR OF DAYS DELINQUENT X DATL¥ INTEREST FACTOR
--Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (15) days
beyond the date of the assessment. If payment is made after the interest computation date shown on the
Notice, additional interest must bm calculated.
REOORDED OFFICE OF
LAW OFI~:0 ,~ /~/~ I ~
BARBARA. SVMPL~- ~L~V~N
O~PH~'S COURT
December 28, 2004
Register of Wills
Cumberland County Courthouse
1 Courthouse Square
Carlisle, PA 17013
Re: Estate of Albert Rabena
No. 21-03-0330 / Cumberland County
Dear Sir/Madam:
Pursuant to your Notice of Inheritance Tax dated November 29, 2004, enclosed please
find a check in the amount of $5.23 for payment of the additional tax due on the above
referenced Estate.
Should you have any questions please contact my office.
Verytriily - '
Barbara Sumple-Sullivan
BSS/lh
Enclosures
BUREAU OF INDIVZDUAL TAXES
BARBARA SUNPLESULLIVAN ES
5q9 BRIDGE ST
NE# CUMBERLAND PA 17070
COHNONNEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
R AX
ST~~A~OUNT
DATE OF DEATH
OFFILE NUNBER
11-29-200q
RABENA
03-08-2003
21 05-05S0
CUMBERLAND
101
Amoun~ RemA%%~d
ALBERT
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17015
NOTE: To /nsurs pPopeP credtt to your Iccount, subs~t the upper poPtton of this form
CUT ALONG THIS LZNE
. . ~m~ RETAINLONER PORTZON FOR YOUR RECORDS
R~,r: f&~Y IF'~N~"¢O%I'~]3 ...... ';;~'~41M~%Nfl~"f~"~Y~R&~Tf'ttl~'~5%,~0~4y--;~-~ .....................
ESTATE OF RABENA ALBERT FZLE ND. 21 03-0350 ACN 101 DATE 11-29-200r~
THIS STATEMENT TS PROVIDED TO ADVZSE OF THE CURRENT STATUS OF THE STATED ACN IH THE NAILED ESTATE. SHONN SELON
IS A SUHMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE~
A PROJECTED INTEREST FIGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT= 05-51-200~
PRINCIPAL TAX DUE:.
PAYMENTS (TAX CREDITS)~
PAYMENT RECEIPT DISCOUNT (+)
DATE NUMBER INTEREST/PEN PAID (-) AMOUNT PAID
06-05-2005
11-05-2005
O$-lO-ZOOq
IO-I$-ZO0~
COOOZ65q
CD003515
WRITEOFF
CDO0~93
39q.7q
.00
.00
q6.1q-
7,500.00
768.06
23.3q
2,197.65
BALANCE OF UNPAZD ZNTEREST/PENALTY AS OF lO-lq-ZOOq
IF PAID AFTER THIS DATE~ SEE REVERSE
SZDE FOR CALCULATION OF ADDITIONAL INTEREST.
( ZF TOTAL DUE ZS LESS THAN $1~ NO PAYMENT ZS RE~UZRED.
ZF TOTAL DUE ZS REFLECTED AS A "CREDIT" (CR],
TOTAL TAX CREDIT 10,81q.31
BALANCE OF TAX DUE .00
INTEREST AND PEN. 5.25
TOTAL DUE 5.23
YOU MAY BE DUE A REFUND. SEE REVERSE SlOE OF THIS FORH FOR INSTRUCT~D#S. !
-- If R/SIDENTI]ECEBENT make check or money order payable to: REGZSTER OF #ZLLS, AGENT*
-- If NON-RESIDENT DECEDENT make check ar m=ne~ arder payable to: COHlflOHt~EALTH OF PENNSYLVANIA,
REPLY TO:
XNTBREgT = BALANCE OF TAX UNPAZD X NUHBER OF DAYS DNLZNQUBNT X DAXLY ZNTBREST FACTOR
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
REV-1162 EX(11-96)
NO. CD 004778
SUMPLE-SULLIVAN BARBARA
549 BRIDGE STREET
NEW CUMBERLAND, PA 17070
ESTATE INFORMATION: SSN: 172-0~-0352
FILE NUMBER: 2103- 0330
DECEDENT NAME: RABENA ALBERT
DATE OF PAYMENT: 12/29/2004
POSTMARK DATE: 1 2/28/2004
COUNTY: CUMBERLAND
DATE OF DEATH: 03/08/2003
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 $5.23
TOTAL AMOUNT PAID:
$5.23
REMARKS:
SEAL
CHECK# 7041
INITIALS: JA
RECEIVED BY:
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
PO BOX 280601
HARRISBURG PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
STATEMENT OF ACCOUNT
*'
REV-1U7EX aFP C12-G4J
';'
" 1'-; 2Ll
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
01-31-2005
RABENA
03-08-2003
21 03-0330
CUMBERLAND
101
A.lKNnt R...i tted
ALBERT
BARBARA SUMPLESULLIVAN ES
549 BRIDGE ST
NEW CUMBERLAND PA 17070
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
NOTE: To insure proper credit to your account} submit the upper portion of this for. with your tax paYMent.
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
ftW :r&fl.,.!r..(W.rlll':..d'.!'.........ii.."f'A~f'I'A'Nl!r"flr.~tl~Al'N'I'.'b'l!'.lr:i!'d'OJIY...ii'.................... ...
ESTATE OF RABENA ALBERT FILE NO.21 03-0330 ACN 101 DATE 01-31-2005
THIS STATEHENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAHED ESTATE. SHOWN BELOW
IS A SUHHARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYHENTS, THE CURRENT BALANCE, AND, IF APPLICABLE,
A PROJECTED INTEREST FIGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 05-31-2004
PRINCIPAL TAX DUE:.
10,814.31
PAYMENTS (TAX CREDITS):
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
IElEl' SUMMARY OF ~LL 005 PAYMENTS IElEl.
12-28-2004 394.74 .00
12-28-2004 51. 37- 10,494.28
TOTAL TAX CREDIT 10,814.31
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
. IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .00
SIDE FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1,
ND PAYHENT IS REQUIRED.
'\
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CRlJ
YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FDRH FOR INSTRUCTIONS. )