HomeMy WebLinkAbout07-13-11 (3)._.I 150561^148
REV-1500 EX (01-10)
PA' Department of Revenue OFFlCIAL USE ONLY
County Code Year File Number
Bureau oilndhriduaiTaxes INHERITANCE TAX RETURN
Po Box zsasoi 21 1 D 12 6 ^
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
222-12-8015 22112010 12251924
Decedent's Last Name Suffix Decedents First Name M I
HESS ROBERT K
(If Applicable) Enter Surviving Spouse's information Below
Spouse's Last Name Suffix Spouse's First Name M I
Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
- - REGISTER OF WILLS
FILL IN APPROPRIATE BOXES BELOW
® 1. Original Return
^ 4. Limfted Estate
e. Decedent Died Testate
{Attach Copy of tNll)
^ 2. Supplemental Retum
^ 4a. Future Interest Comprmrtise (date of
death after 12-12-82)
^ 7. Decedent Maintained a Living Trust
(Attach Copy of Trust)
^ 3. Remainder Retum {date of death
prior to 12-13-82)
^ 5. Federal Estate Tax Retum Required
+~ 8. Total Number of Safe Deposit Boxes
9. Litigation Proc~ds Received 10. Spousal Poverty Credit (date of death 11. Election to tax under Sec. 91 i3(A)
between 12-31-91 and 1-1-95) (Attach Sch. O}
C'-ORR.ESPONDENT - TiitS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFiDEN7!AL TAX INFORMATION GHOULD BE D!RECTEI:7 T Q;
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PLEASE %iSE ORIGINAL FORiVi ONLY
5td6 ~
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Estate of Robert K. Hess
Executors (Page 1)
Name Richard D. Hess
Address 862 Kirkwood Pike
Quarryville, PA 17566-
Tax ID 205-92-3051
Name Betty J. Sollenberger
Address 856 Kirkwood Pike
Quarryville, PA 17566-
Tax ID 165-42-4884
222-12-8015
150561D248
REV-1500 EX
Decedent's Social Security Number
222-12-8015
Decedent's Name: HESS ROBERT K
RECAPITULATION
1. Real Estate (Schedule A) 1 D - D D
2. Stocks and Bonds (Schedule B) . 2
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) , 3
4. Mortgages and Notes~Receivable (Schedule D) 4
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E) 5.
6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested g
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) ~ Separate Billing Requested 7.
8. Total Gross Assets (total Lines 1 through 7) 8
25,686•^0
0.00
82,540.00
25,254.00
0.00
26,981.00
160,461.00
9. Funeral Expenses and Administrative Costs (Schedule H), , g
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) 10
11. Total Deductions (total Lines 9 and 10) , 11
12. Net Value of Estate (Line 8 minus Line 11) 12.
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) , , 13.
14. Net Value Subject to Tax (Line 12 minus Line 13) 14.
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers un~jer Sec. 9116
16. Amount of line 14 t xable
4
~
.
at lineal rate x .0
12 9, 6 0 6• D O 1 s.
17. Amount of Line 14 taxable
at sibling rate X .12 D • D D 17.
18. Amount of Line 14 taxable
at collateral rate X .15 D • D D 18.
19. TAX DUE 19.
20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
15D561D248 ],505610248
9M4648 4.000
16,239•^0
14,617.00
3D,856.00
129,605.00
0•DO
129,605.00
O.oD
5,832.00
D•oD
0.00
5,832.00
REV-1500 EX Page 3
Decedent's Complete Address'
File Number
a~. i.n l.7Ln
DECEDENTS NAME
HESS ROB RT K
STREET ADDRESS
M R AN 0 NTY
CITY
f1ECHANICSBURG STATE
PA ZIP
17055-
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments 5, 0 0 0. 0 0
B. Discount 2 6 3.0 0
3. Interest
(1) 5, 832 • 00
Total Credits (A + B) (2)
5,263.00
(3) 0 • 0 0
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in box on Page 2, Line 20 to request a refund. (4)
0.00
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 5 6 9 • 0 0
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and:
a. retain the use or income of the property transferred;
b. retain the right to designate who shall use the property transferred or its income;
c. retain a reversionary interest; or . .
d. receive the promise for life of either payments, benefits or care?. Yes
^ No
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? . .
3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death?
^
4. Did decedent own an individual retirement account, annuity, or other non-probate property, which
contains a beneficiary designation?
®
^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is
3 percent [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an
adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)J.
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in
72 P.S. §9116(1.2) [72 P.S. ~9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent (72 P.S. ~9116(a)(1.3)]. A sibling is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
9M4671 2.000
REV-1503 EX + (6-98)
SCHEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ATE OF
FILE NUMBER
Robert K. Hess 21 10 1260
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
t. Raymond James Mutual Fund Account #82539400 25,686
TOTAL (Also enter on line 2, Recapitulation) ~ $
25,686
3wasss ~.ooo (If more space is needed, insert additional sheets of the same size)
REV-1507 EX + (5-96)
SCHEDULE D
COMMONWEALTH OF PENNSYLVANIA MORTGAGES & NOTES
INHERITANCE TAX RETURN
RESIDENT DECEDENT RECENABLE
ESTATE OF
FILE NUMBER
Robert K. Hess
21 10 1260
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER DESCRIPTION VALUE AT DATE
OF DEATH
1 Deferred Payment Receivable from Parke and Betty
Sollenberger for real estate purchased from decedent in
the original principal amount of $150,000.00, payable
over 15 years at 4.8$ interest at $1170.62 per month and
payment number 97 was made prior to decedent's death.
See first and third pages of amortization schedule
attached.
82,540
TOTAL (Also enter on line 4, Recapitulation) $
82,540
3wg6AC t.o0o (If more space is needed, insert additional sheets of same size)
REV-1508 EX + (8-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, 8 MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
Robert K. Hess 21 10 1260
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Household items and furnishings 500
2 Fulton Bank Money Market Account #9904-88613 1,887
3 Susquehanna Bank Certificate of Deposit #1523838532 3,000
Interest accrued to 12/11/2010 1
4 Susquehanna Bank Checking Account #1523838501 4,415
5 Final Met Life Annuity Payment 70
6 Cash proceeds from sale of scooter 100
7 Verizon refund 9
8 Mutual of Omaha refund 653
9 Cash proceeds from sale of walker 20
10 Cash in wallet 69
11 Pennsylvania 2010 individual income tax refund 320
12 Federal 2010 individual income tax refund 216
13 Highmark Insurance Refund 92
14 Messiah Village Refund Due Under Acquisition Agreement 13,902
TOTAL (Also enter on line 5 Recapitulation) $ ~ 25 , 254
3wasnD t.ooo (If more space is needed, insert additional sheets of the same size)
REV-1510 EX + (08-09)
pennsylvania
DEPARTMENT OFREVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS AND
MISC. NON-PROBATE PROPERTY
ESTATE OF ru_t Ivum~stK
Robert K. Hess 21 10 1260
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
ITEM
NUMBS
DESCRIPTION OF PROPERTY
INCLLDETFEN4MEOFTFETRANSFEREE.THEIRRELATIONSHIPTODECEDENiAND
THE DATE OF TRANSFER. ATTACHACOPY OF THE DEED FOR REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET
o
/o OFDECD'S
INTEREST
EXCLUSION
IF APPLICABLE ---_
TAXABLE
VALUE
~ Kemper Scudder Destination
Annuity Contract #KI11041924 26,981 100.0000 0 26,981
Beneficiaries are children,
Richard D. Hess and Betty J.
Sollenberger, in equal shares.
2 1986 S-10 Chevy Pick-up 500 100.0000 500 0
Transfered to son, Richard D.
Hess, within one year of
decedent's death.
TOTAL (Also enter on line 7, Recapitulation) $ ~ 2 6 , 981
If more space is needed, use additional sheets of paper of the same size.
9W46AF 2.000
REV-1517 EX+110-09) SCHEDULE H
Pennsylvania
DEPPRTMENTOF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Robert K. Hess 21 10 1260
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
~ Reynolds Funeral Home 8,521
B.
1
ADMINISTRATIVE COSTS:
Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City
Year(s) Commission Paid:
2. Attorney Fees: 6, 750
3, Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: 210
5. Accountant Fees:
6. Tax Return Preparer Fees: 2 65
7.
1 Miscellaneous expenses to close estate (income taxes) 200
2 Susquehanna Bank (finance charge) 5
3 Persun & Heim, P.C. (legal Costs) 288
State ZIP
TOTAL (Also enter on Line 9, Recapitulation) ~ $ 16 , 239
swasnc z.ooo If more space is needed, use additional sheets of paper of the same size.
REV-1512 EX+I,Z_ae, SCHEDULE
pennsylvania
DEPARTMENTOF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES 8c LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Robert K. Hess 21 10 1260
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Paul Dalbey, DPM (physician bill) 25
2 Messiah Village Home Care (nursing home transportation costs) 335
3 Messiah Village (nursing home care costs) 13,979
4 (Alert Pharmacy (prescription costs)
TOTAL (Also enter on Line 10, Recapitulation) ~ $
awasAH z.ooo If more space is needed, insert additional sheets of the same size.
278
14,617
REV-1513 EX+ (01-10)
pennsylvania
DEPARTMENTOFREVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF: FILE NUMBER:
Robert K. Hess ___ 2110 1260
IMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under
Sec. 9116 (a) (1.2).j
1, Betty J. Sollenberger
856 Kirkwood Pike
Quarryville, PA 17566
50~ of Residue: 64,803
2 Richard D. Hess
862 Kirkwood Pike
Quarryville, PA 17566
50~ of Residue: 64,803
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
Do Not List Trustee(s) OF ESTATE
Daughter
Son
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE.
[[ NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1
6. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1
64,803
64,803
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. ~ $ 0
If more space is needed, use additional sheets of paper of the same size.
swasa z.ooo
ARNING: It is illega{ to duplicate this copy by photostat or photograph.
ee for this certificate.. X6:00
P 17151277
Certification Number
This is to .certify that the information here given
correctly copied from an original Certificate of Dea
.duly filed with me as <Local Registrar. The origin
.certificate will be forwarded to the State Vit
.Records Office for permanent filing.
. ~~~~ "~- - ~~r>~i•-~ DEC/ 1 '5 ~ 010
Local Registrar Date~Issued
110`rN7 flEVJl!l006 COMMONWEALTH OF PENNSYLVANIA •-:DEPARTMENT OF HEALTH • VITAL RECORDS
PeEfluuie~ CERTIFICATE OF DEATH
BUCK INN (See instructions and examples on reverse)
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Dispoailbn Perm) No. D 5 3 ~ Y~b '
Last Will ~zncl Test~zmev~t
of
Robert K. Hess
I, ROBERT K. HESS, of Quarryville, Lancaster County, and Commonwealth of
Pennsylvania, make this my Last Will and revoke any and all of my prior Wills.
ARTICLE I. PAYMENT OF DEBTS AND FUNERAL EXPENSES. I direct my Executor to pay
all my just debts and funeral expenses from my estate.
ARTICLE II. TRANSFER OF PERSONAL AND HOUSEHOLD ITEMS. My automobiles,
clothing, jewelry, books, pictures, furniture, furnishings, and other personal or household items
shall be transferred according to a list which I intend to attach to this Will. If there is no list, or
to the extent that any such items are not included on the list, then such personal and household
items shall be paid over and transferred to my children according to their own arrangements. If
they cannot agree or arrange for a division in a friendly way, then my Executor may distribute or
dispose of those items in any way he deems to be fair, including private sales or a public sale.
If any minor becomes entitled to any items under this Article, those items may be delivered to
the minor whenever my Executor decides, provided that the transfer shall take place not later
than the date when the minor reaches the age of twenty-one (21) years.
ARTICLE III. RESIDUE AND REMAINDER. All the remainder of the property that I may own
or that I may be entitled to dispose of or to appoint at the time of my death shall be divided into
hess robert will 11/14/02 #5304291
two equal shares. I give, devise, bequeath, and appoint one (1) equal share to each of my
children.
Any reference to my "child" or "children" shall refer to Betty J. Sollenberger and
Richard D. Hess. Any reference to the masculine in my Will as it relates to my child or children
shall also include the feminine wherever necessary.
In the event that any child fails to survive me and leaves issue, then I give,
devise, and bequeath that deceased child's share in equal parts to the issue of that deceased
child, per stirpes. The share of any such issue under the age of twenty-one (21) years shall be
paid over and transferred to a Trustee, INTRUST, NEVERTHELESS, for such issue and that
trust shall be administered as a separate trust for that issue according to the terms of Article IV
below.
In the event that any child fails to survive me and leaves no issue, then 1 give,
devise, and bequeath that deceased child's share in equal shares to my other child(ren), per
stirpes.
ARTICLE IV. TERMS OF TRUST FOR DECEASED CHILD'S ISSUE. The share of any issue
of a deceased child shall be paid over and transferred to a Trustee, IN TRUST,
NEVERTHELESS, for such issue if such issue is under the age of twenty-one (21) years at the
time a distribution is to be made to such issue. The share of each such issue under the age of
twenty-one (21) years shall be administered as a separate trust for such issue according to the
following terms and provisions. The Trustee shall pay over or use, apply, and expend income
or principal or both for such issue in such amounts as the Trustee, in his sole discretion, shall
deem advisable in order to provide health, support, maintenance, and education for such issue.
At the time when such issue attains the age of twenty-one (21) years, that issue shall have the
2
right to withdraw all the accumulated income and the entire remaining principal, and the
separate trust for such issue shall then terminate.
Should the principal of any such trust become too small, in the Trustee's sole
discretion, so as to make the continuance of the trust inadvisable, the Trustee may terminate
the trust and make immediate distribution of the then remaining principal and any accumulated
income or undistributed income outright to such issue, and the rights of any other potential
beneficiaries of such trust shall automatically cease and determine.
The Trustee of each such trust for the issue of a deceased child of mine shall be
appointed by the court that has jurisdiction of this type of matter at that time.
ARTICLE V. APPOINTMENT OF EXECUTOR. I appoint my children, Betty J. Sollenberger
and Richard D. Hess, to be Executors of this my Last Will.
Any reference to "Executor" in my Will shall be deemed and taken to include each and
every person or party named or appointed to serve as the personal representative of my estate,
whether there is one or more than one. Also, any reference to the masculine in my Will as it
relates to my Executor shall also include the feminine and the neuter wherever necessary. In
the event that a co-executor is unable or unwilling to act or to continue to act in said office, then
the other(s) may serve or continue to serve without the need for the appointment of another
co-executor. Also, in the event that co-fiduciaries have been named for one or more of the
fiduciary positions above, then a decision of the said fiduciary shall be made by a simple
majority of the co-fiduciaries.
ARTICLE VI. WAIVER 01= BOND. To the extent that such requirements can legally be waived,
I direct that no Executor named in my Will or any persons succeeding in that office, whether in
3
the Commonwealth of Pennsylvania or elsewhere, shall ever be required to post any bond or
give any security in connection with his duties.
ARTICLE VII. EXECUTOR'S POWERS. In addition to powers given him by law and by other
provisions of my Will, my Executor shall have the following powers, applicable to all property
held by him, and these powers shall be effective without court order and until actual distribution:
A. To sell at public or private sale, mortgage, exchange, transfer, or lease for any
period of time any real or personal property and to give options for sales, exchanges, or leases
for such prices and upon such terms or conditions as he deems proper. No purchaser shall be
held liable to see to the application of any purchase money;
B. To retain any and all of the assets of my estate, real or personal, in the sole
discretion of my Executor, without being restricted to investments authorized for Pennsylvania
fiduciaries and without regard to any principle of diversification or risk;
C. To delegate. discretionary powers to agents, remunerate them, and pay their
expenses;
p, To collect rents and other proceeds from real estate, paying all carrying charges
and making such repairs as he may deem proper, all without the necessity of obtaining leave of
any court;
E. To carry on any business owned or controlled by me at the time of my death for
whatever period of time he shall think proper, with full powers in the property, including the
power to borrow and to pledge assets contained in my estate as security for said borrowings;
F. To exercise any rights or elections to pay death taxes in installments and to
make interest payments on such installments as a charge against the principal of my estate;
G. To disclaim on my behalf any interest as my Executor deems advisable.
4
All the foregoing powers, together with those granted by law to executors, may
be exercised by the Executor named in my Will and by all persons succeeding in said office,
including administrators with Will annexed.
ARTICLE VIII. APPORTIONMENT OF TAXES. All taxes payable by reason of my
death, together with any penalties thereon, shall be paid out of my residuary estate, without
reimbursement from or apportionment among the beneficiaries, recipients, or owners of such
property for any such taxes, penalties, or interest.
IN WITNESS WHEREOF, I, Robert K. Hess, the Testator, have to this my Last Will,
typewritten on five (5) sheets of paper (including the witnesses' signatures), of which this is
r
Sheet No. 5, set my hand and seal this ~ ~ ~~ day of .~~?V'~ /~'1 ~'1 '~ i" , 20GZ--
/~~2~'~' t ~ ~~ (SEAL)
Robert K. Hess
SIGNED, SEALED, PUBLISHED, AND DECLARED, by Robert K. Hess as and for his
Last Will, in the presence of us, who at his request and in his presence and in the presence of
each other, have hereunto subscribed our names as witnesses this ~ ~`~ day of
~11r~ t~~ n2 ~~ ter- , 20 ~z:
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Town and State
5
ACKNOWLEDGMENT AND AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
SS.
COUNTY OF ,~ ~lif ~/-~ ~ ~~
The Testator, Robert K. Hess, whose name is signed to the foregoing instrument and
the witnesses whose names are signed to the foregoing instrument, being duly qualified
according to law, do hereby declare to the undersigned authority that the Testator signed and
executed the instrument as his Last Will; that he signed willingly and that he executed it as his
free and voluntary act for the purposes therein expressed; that each of the witnesses, in the
hearing and presence of the Testator, signed the Will as.a witness; and that to the best of their
knowledge and belief the Testator was at that time eighteen (18) years of age or older, of sound
mind and under no constraint or undue influence.
L~!`~7~L'~,~C`~~ (SEAL)
Robert K. Hess
~_
~~ ~'~^~ (SEAL)
Witness
~~~ ~ ~, ~I (SEAL)
Witness
i.~i ~~ `~~.~ %%n~ (SEAL)
,~Nitness
Subscribed, sworn to and acknowledged befi
and ubscribed and sworn to before me by _~~;;
~~~ (~~ tC ~i ~ ~1,~ ~~~ ,and ~_ ,4
the witnesses, this ~~_ day of rV c ~r~--~ ~.-~ --
ire me by Robert K. Hess, the Testator,
20 0 ~,
,.~-.~ ~ ~.,,.- (Notary Public)
Notarial Seal I~blic
Melisa M. Lucas, Notary
MytCommission E~p resuocL ~ ~u2003
Member, Pennsylvania Association of Notaries
:304391 1
R 485 X (3 04)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128A601
JCf ~
SAFE DEPOSIT BOX
INVENTORY
Please Print or Type
MUST BE COMPLETED BY REPRESENTATIVE OF FINANCIAL INSTITUTION WHERE SAFE DEPOSIT BOX IS LOCATED AND RETURNED TO ABOVE ADDRESS
COUNTYCOOE FILE NUMBER SOCIA S CURffY(Re ulred-ORD ATHC RTIFICAT NU B R(onNifSSNisunknown)
• DECEDENT'S NAME ( T, FIRST, MIDDLE) DATE OF DEATH
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SAFE DEPOSIT BOX INVENTORY Page~of
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INSTRUCTIONS
The Department is authorized under federal law , 42 U.S.C. § 405(c), to use the decedent's Social Security number in
administering this state tax law. The Department uses Social Security numbers to establish a decedent's identity and
ensure proper credit for tax payments.
(1) Cash: Report total only.
(2) Stocks: List in detail every common or preferred certificate, warrant or other rights found in box. Stocks are to be
designated by name of company, certificate number, date of certificate, name in which stock is registered, and
number of shares and class of stock.
(3) Obligations of U.S. Government: Number of items, date of issue, face value, names in which registered and
type of ownership, i.e., jointly held, payable on death, etc.
(4) Bonds: Designate by name, amount, serial number, or other designation. (Bearer Bonds)
(5) Bank and Savings and Loan Passbooks: State name of depositor, number of book, last date appearing in book,
name of bank and branch, and balance.
(6) Jewelry, Coins, Stamps, Manuscripts, etc: List and describe as fully as possible.
(7) Deeds, Mortgages, Current Insurance Policies or other evidences of indebtedness: List and describe as fully
as possible.
(8) All other contents.
ITEM
NO. ITEM DESCRIPTION
I CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS
CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. PERSON RECEIVING COPY OF
SAFE DEPOSIT BQJC INVENTORY:
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PRINT-~J E ~ ~~ ~ - _ ~ ~ ~ ~
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u tstale Representative ~ Joint owner of safe deposit box
NOTE: Attach additional 8'/:° x 11" sheet(s) if necessary or use duplicates of this page of form.
~:AYIVIOND A1~//~ESG
FINANCIAL SERVICEB, INC.
Member NASD /SIP C
December 14, 2010
Gary J. Heim, Esq.
Persun & Heim, P.C.
P.O. Box 659
Mechanicsburg, PA 17055-0659
Re: Robert K. Hess
Raymond James Account # 82539400
Kemper Scudder Destinations Annuity Contract KIl 1041924
Dear Attorney Heim;
Jay W. Charles, M.B.A., C.I.M.A.
Investment Consultant
Eric C. Peinhardt
Financial Advisor
Scott E. Bauermaster
Financial Advisor
Please extend our deepest sympathies to the family in the loss of Mr. Hess.
Attached please find an Unrealized Gain and Loss report for Mr. Hess's Raymond James
account as per his date of death, December 11, 2010. An Account Information and Client
Agreement is also attached to transfer his account to an Estate Account. The Executor/s
will have to complete the highlighted areas and sign where indicated. We will also need
an original Letter of Administration.
Also, be advised that his Kemper Scudder Destination Annuity contract value as of close
on Friday, December 10, 2010 was $26,980.81. As per Kemper Annuities, Richard Hess
and Betty Sollenberger are beneficiaries of the annuity contract, 50% each.
Attached please find the Claim Forms to be completed by each Richard and Betty. A
certified death certificate is also required.
Thank you Attorney Heim, and if we can be of any further assistance, please feel free to
contact us at 717-464-0100.
Sincerely,
Jill D. Groff
Administrative Assistant
Raymond James Financial Services
208 Willow Valley Square, Lancaster, PA 17602
717.464.0100 Fax: 717.464.2979
Raymond James Financial Services, INC.
UNREALIZED GAINS AND LOSSES
Robert K Hess
C/O Betty Sollenberger
ACCOUNT # 82539400
December I1, 2010
(Excluding Reinvested Divs.)
Unit Total
Date Quantity Security Cost Cost Price
Mutual Funds
OS-10-06 1,157.726 Wells Fargo Advantage 12.77 14,788.56 11.63
Asset Alloc- Ation F
Fixed Income Mutual Funds
03-31-]0 1,]05.872 Jp Morgan Short 10.86 12,013.65 11.03
Duration Bond Fund
Class C
Market Unrealized
Value Gain/Loss G/L
13,464.35 -1,324.21 -9.0
13,464.35 -1,324.21 -9.0
12,197.77 184.12 1.5
1.~
U.S. Cash Accounts 24 24 24.24
Rj Bank Deposit Program Money
Market Fund
24.24 24.24
26 826:45- ''5;686:36 =I140:09 =4:2
~QTAL PORTFOI310 - ` .,+_, - _ r .
BOND AND WARRANT
KNOW ALL MEN BY THESE PRESENTS THAT Betty J. Sollenberger and Parke E.
Sollenberger, of Colerain Township, Lancaster County, Pennsylvania, party of the first part,
hereinafter referred to as "Obligor," are held and firmly bound unto Robert K. Hess, widower, of
Colerain Township, Lancaster County, Pennsylvania, party of the second part, hereinafter referred
to as "Obligee," in the sum of Two Hundred Thirty Thousand and 00/100 ($230,OD0.00) Dollars
lawful money of the United States of America, to be paid to the said Obligee, his certain attorney,
executors, administrators, successors or assigns. To which payment, well and truly to be made,
he does bind himself and his heirs, executors, and administrators, and every of them, firmly by
these presents.
THE CONDITION OF THIS OBLIGATION IS SUCH that if the said Obligor, his heirs,
executors, or administrators, or any of them, shall and do well and truly pay, or cause to be paid,
unto the said Obligee, his certain attorney, executors, administrators, successors or assigns, the
sum of Two Hundred Thirty Thousand and 00/100 ($230,000.00) Dollars, together with interest
.according to the terms set forth below, without any fraud or further delay, and also from time to
time, and at all times, until payment of the said principal sum be made, as aforesaid, keep the
building(s) erected and to be erected upon the land described in the Mortgage accompanying this
Bond insured for the benefit of the Mortgagee, to an amount of at least One Hundred Twenty-Five
Thousand and 00/100 ($125,00.0.00-) Dollars and to take out no insurance on said building(s) not
marked for the benefit of the Mortgagee, then the above obligation to be void, or else to be and
remain in full force and virtue.
AND the further condition of this obiigation is such, that if at any time default shall~be made in
the payment of principal or interest as aforesaid, for the space of fifteen (15) days after any
payment thereof shall fall due, or if a breach of any other of the foregoing conditions be made by.
the said Obligor, his heirs, executors, administrators, or assigns, then, and in such case, the said
principal sum shall, at the option of the said Obligee, his certain attorney, executors,
administrators, successors or assigns, become due; and payment of the same with the interest
and cost of insurance due thereon, as aforesaid, together with an attorney's commission of ten
(10%) percent on the said principal sum, besides costs of suit, may be enforced and recovered at
once; anything herein contained to the contrary thereof in anywise notwithstanding.
AND FURTHER Obligor does hereby empower any Attorney of any Court of Record of the
Commonwealth of Pennsylvania to appear for him and, with or without a declaration filed in his
name, to confess a judgment or judgments in favor of the above-mentioned Obligee, his
executors, administrators, successors or assigns and against Obligor for the penal sum above
mentioned, with costs of suit, with a full release of all errors, and without stay of execution after
any default as aforesaid. And Obligor also waives the right of inquisition upon any real estate
which may be levied upon to collect the said sum, and he does hereby voluntarily condemn the
same, and authorize a writ of execution to be issued upon the judgment obtained upon this
obligation, or by virtue of the warrant of attorney hereto attached, or an action of mortgage
foreclosure properly commenced upon the accompanying indenture of mortgage. And the said
Obligor does hereby waive and release to the said Obligee, his executors, administrators,
successors, and assigns, the benefit and advantage of all laws now in force, or that may be
hess roberi bond and warrant 11/14/02 #304162(a)
passed, exempting property, either real or personal, or both, from levy and sale under any
execution that may be issued, for the collection of the said judgment.
The Two Hundred Thirty Thousand and 001100 ($230,000.00_) Dollar principal sum herein
shall be paid according to two different schedules: (1) Eighty Thousand and 00/100 ($80,000.00)
Dollars thereof shall not accrue interest for two (2) years through November 13, 2004 and
thereafter it shall accrue interest at the rate of four and eight tenths (4.8%) percent interest and
shall be paid over a period of thirteen (13) years in equal monthly amounts of Six Hundred Ninety
and 35/1'00 ($690.35) Dollars starting December 14, 2004 and continuing through November 14,
2017; and (2) One Hundred Fifty Thousand and 00/100 ($150,000.00) Dollars-with interest at the
rate of four and eight tenths (4.8%) percent .per annum, said interest to be calculated monthly on
the unpaid balance of the principal indebtedness (such interest to be computed on .the unpaid
balance of the loan at the beginning of each month and charged against the loan before
application of the payment for the month) and,'if not paid by the last day of the month, said interest
shall be added to the principal indebtedness. The said principal sum and interest shall be paid in
one hundred eighty (180) equal monthly payments of One Thousand One Hundred Seventy and
62/100 ($1,170.62) Dollars each. The first monthly payment of principal and interest hereunder
shall be made on or before December 14, 2002. Equal monthly payments shall be made each
consecutive month thereafter by the fourteenth (14th) day of each month. Notwithstanding any
provision herein to the contrary, all principal and interest due hereunder shall be paid in full by
November 14, 2017.
The payments made by Obligor shall be applied first to interest and thereafter to principal.
Obligor shall have the right to prepay the principal obligation hereunder, in whole or in part, at any
time provided, however, that the $150,000.00 portion of the scheduled obligation shall not be
prepaid without Obligee's written approval during his lifetime, but after Robert K. Hess's death, that
$150,000.00 portion of the scheduled obligation can be prepaid at any time by Obligor without
penalty. There shall be no penalty for such prepayments. No prepayments shall reduce the
amount of or extend the due date of the next scheduled monthly payment, but instead shall
shorten the term of this obligation.
IF THIS INSTRUMENT is executed by more than one person or corporation or both as
Obligor, the authorizations, obligations, responsibilities, liabilities, and waivers of each shall be joint
and several. Whenever used, the singular number shall include the plural, the plural the singular,
the use of any gender shall include all genders, and the words "Obligor" and "Obligee" wherever
used, shall include their heirs, executors, administrators, successors, or assigns.
Signed, sealed, and delivered this ~ ~l''1 day of ~~~%' ~`~~~ !-~~r" , 20~'?-
Witness:
r
.a-,~--
~'-.~ ti .(Seal)
t J. Sollenberger ;
~ _ C ~. ~n-2~~.C . sz1--('Seal)
Parke E. Sollenber~e~
2
WAIVER
1. On the same date that this Waiver is being signed, the undersigned executed and
delivered to Robert K. Hess a bond and warrant in the penal amount of Two Hundred Thirty
Thousand and 00/100 ($230,000.00) Dollars which authorizes the immediate entry of judgment
against him/them.
2. The undersigned have been told and are aware of the fact that judgment may be entered
against them and that in the event of default in payment of the bond and warrant or of any
installment when due, an execution may be issued against them without further notice to them and
a levy may be made upon real estate and personal property which may be sold to satisfy said
judgment.
3. The said bond and warrant has been so executed and delivered by the undersigned
voluntarily and in full knowledge of all the foregoing and in full knowledge of their constitutional
rights and has been signed intelligently and willingly.
4. The undersigned hereby waive all of such rights to notice and hearing before entry of
judgment and before any execution, levy, or sale.
5. The undersigned agree to the entry of said judgment.
IN WITNESS WHEREOF and INTENDING TO BE LEGALLY BOUND, t e undersigned has/
have executed this Waiver and the original bond and warrant on the % day of
~G'V'~ i~-~ ~ ter- 20~~
,~ ; ' . ~,% < ' ~~ ~ ~ti (SEAL)
ty J. Sollenberge~~
C' (1 ,1 ~,~ - .(SEAL)
Parke E. Sollenberg
before me this ~ day
<----~~
~~-i~.~ /`'7,-,~ tic<~
Notary Public
Notarial Seal
Melisa M. Lucas, Notary Public
City of Harrisburg, Dauphin County
A4y Commission Expires Oct. 13, 2003
t:~iember, Pennsyh~ania issxiation of IVoiaries 3
:304162 1
SWORN TO AND SUBSCRIBED
Amount
~~ Borrowed
150,000.00
Loan Loan 1st Pmt
Date -Rate o Date
#o"f Last Pmts
Pds Pmt Date /Yr Payment Pts APR o
1 12/14/02 600.00
---- 570.62
---------- 149,429.38 600.00
------------------
Subtotal: ------------
600.00 570.62 149,429.38 600.00
2 1/14/03 597.72 572.90 148,856.47- 1,197.72
3 2/14/03 595.43 575.20 148,281.28 1,793.14
4 3/14/03 593.13 577.50 147,703.78 2,386.27
5 4/14/03 590.82 579.81 .147,123.98 2,977.08
6 5/14/03 588.50 582.13 146,541.85 3,565.58
"7 6/14/03 586.17 584.45 145,957.40 4,151.75
8 7/14/03 583.83 586.79 145,370.60 4,735.58
9 8/14/03 581.48 589.14 144,781.46 5,317.06
10 9/14/03 579.13 591.50 144,189.97 5,896.18
11 10/14/03 576.76 593.86 143,596.11 6,472.94
12 11/14/03 574.38 596.24 142,999.87 7,047.33
13 12/14/03 572.00 598.62 142,401.25 7,619.33
~USubtotal• 7,019.33 7,028.13 142,401.25 7,619.33
14 1/14/04 569.60 601.02 .141,800.23 8,188.93
15 2/14/04 567.20 603.42 141,196.81 8,756.13
16 3/14/04 564.79 605.83 140,590.98 9,320.92
17 4/14/04 562.36 608.26 139,982.72 9,883.29
18 5/14/04 559.93 610.69 139,372.03 10,443.22
19 6/14/04 557.49 613.13 138,758.89 11,000.70
20 7/14/04 555.04 615.59 138,143.31 11,555.74
21 8/14/04 552.57 618.05 137,525.26 12,108.31
22 9/14/04 550.10 620.52 136,904.74 12,658.41
23 10/14/04 547.62 623.00 136,281.74 13,206.03
24 11/14/04 545.13 625.49 135,656.24 13,751.16
25 12/14/04 542.62
- 628.00
--------------- 135,028.24
------ 14,293.79
------------------
Subtotal: ---------------
6,674.46 7,373.00 135,028.24 14,293.79
26 1/14/05 540.11 630.51 134,397.74 14,833.90
27 2/14/05 537.59 633.03 133,764.70 15,371.49
28 3/14/05 535.06 635.56 133,129.14 15,906.55
29 4/14/05 532.52 638.11 132,491.04 16,439.06
30 5/14/05 529.96 640.66- 131,850.38 16,969.03
31 6/14/05 527.40 643.22 131,207.16 17,496.43
32 7/14/05 524.83 645;7 9 130,561.37 18,021.26
33 8/14/05 522.25 _6.48.38 129,912.99 18,543.50
x:34 9/14/05 519.65 650.97 129,262.02 19,063.16
35 10/14/05 517.05 653.57 128,608.45 19,580.20
Interest Principal Principal Interest
## Date This Period This Period New Balance To Date
Interest Principal Principal Interest
## Date This Period This Period New Balance To Date
36 11/14/05 514.43 656.19 127,952.26 20,094.64-
37 12/14/05 511.81
---------- 658.81
--------------- 127,293.45
---------------- 20,606.45
--------------
-----
Sub -------------
total: ------
6,312.66 7,734.80 127,293.45 20,606.45
38 1/14/06 509.17 661.45 126,632.00 21,115.62-
39 2/14/06 506.53 664.09 125,967.90 21,622.15
40 3/14/06 503.87 666.75 125,301.15 22,126.02
41 4/14/06 501.20 669.42 124,631.74 22,627.23
42 5/14/06 498.53 672.09 123,959.64 23,125.75
43 6/14/06 495.84 674.78 123,284.86 23,621.59
44 7/14/06 493.14 677.48 122,607.38 24,114.73
45 8/14/06 490.43 680.19 121,927.19 24,605.16
46 9/14/06 487.71 682.91 121,244.27 25,092.87
47 10/14/06 484.98 685.64 120,558.63 25,577.85
48 11/14/06 482.23 688.39 119,870.24 26,060.08
49 12/14/06 479.48 691.14 119,179.10 26,539.56
Sub total: 5,933.11 8,114.35 119,179.10 26,539.56
50 1/14/07 476.72 693.91 118,485.19 27,016.28
51 2/14/07 473.94 696.68 117,788.51 27,490.22
`L--~'52 3/14/07 471.15 699..47 117,089.05 27,961.37
53 4/14/07 468.36 702.27 116,386.78 28,429.73
54 5/14/07 465.55 705.07 115,681.71 28,89.5.28
55 6/14/07 462.73 707.89 114,973.81 29,358.00
56 7/14/07 459.90 710.73 114,263.09 29,817.90
57 8/14/07 457.05 713.57 113,549.52 30,274.95
58 9/14/07 454.20 716.42 112,833.09 30,729.15
59 10/14/07 451.33 719.29 112,113.80 31,180.48
60 11/14/07 448.46 722.17 111,391.64 31,628.94
61 12/14/07 445.57
------- 725.06
--------------- 110,666.58
---------------- 32,074.50
---------------
-----
Sub -------------
total: ---------
5,534.94 8,512.52 110,666.58 32,074.50
62 1/14/08 442.67 727.96 109,938.63 32,517.17
63 2/14/08 439.75 730.87 109,207.76 32,956.92
64 3/14/08 436.83 733.79 108,473.97 33,393.75
65 4/14/08 433.90 736.73 107,737.24 33,827.65
66 5/14/08 430.95 739.67 106,997.57 34,258.60
67 6/14/08 427.99 742.63 106,254.94 34,686.59
68 7/14/08 425.02 745.60 105,509.34 35,111.61
69 8/14/08 422.04 748.58 104,760.75 35,533.65
70 9/14/08 419.04 751.58 104,009.17 35,952.69
71 10/14/08 416.04 754.58 103,254.59 36,368.73
72 11/14/08 413.02 757.60 102,496.99 36,781.74
73 12/14/08 409.99 760.63 101,736.35 37,191.73
Interest Principal Principal Interest
~## Date This Period This Period New Balance To Date
----
Subtotal: --------------
5,117.23
8,930.23
101,736.35
37,191.73
74 1/14/09 406.95 763.68 100,972.68 37,598.68
75 2/14/09 403.89 766.73 100,205.94 38,002.57
76 3/14/09 400.82 769.80 99,436.15 38,403.39
77 4/14/09 397.74 772.88 98,663.27 38,801.14
78 5/14/09 394.65 775.97 97,887.30 39,195.79
79 6/14/09 391.55 779.07 97,108.23 39,587.34
80 7/14/09 388.43 782.19 96,326.04 39,975.77
81 8/14/09 385.30 785.32 95,540.72 40,361.08
82 9/14/09 382.16 788.46 94,752.26
- 40,743.24
83 10/14/09 379.01 791.61 0.65
93,96 41,122.25
84 11/14/09 375.84 794.78 93,165.87 41,498.09
85 12/14/09 372.66
---- 797.96
--------- 92,367.91 41,870.75
------------------
Subtotal• ------------
4,679.02 9,368.44 92,367.91 41,870.75
86 1/14/10 369.47 801.15 91,566.76 42,240.23
87 2/14/10 366.27 804.35 90,762.41 42,606.49
88 3/14/10 363.05 807.57 89,954.84 42,969.54
89 4/14/10 359.82 810.80 89,144.03 43,329.36
~~90 5/14/10 356.58 814.05 88,329.99 43,685.94
91 6/14/10 353.32 817.30 87,512.69 44,039.26
92 7/14/10 350.05 820.57 86,692.12 44,389.31
93 8/14/10 346.77 823.85 85,868.26 44,736.08
94 9/14/10 343.47 827.15 85,041.11 45,079.55
95 10/14/10 340.16 830.46 84,210.66 45,419.71
'
96 11/14/10 336.84 833.78 83,376.88 756.56
45,
9v'~~ 12./1.4x/10 ~ 333 .51
--- 837.11
----------- .~ x,_.53:9°_7=~i 46, 090.06
-------------------
Subtotal• -------------
4,219.31 9,828.15 82,539.76 46,090.06
98 1/14/11 330.16 840.4 6 81,699.30 46,420.22
99 2/14/11 326.80 843.82 80,855.48 46,747.02
100 3/14/11 323.42 847.20 80,008.2 8 47,070.44
101 4/14/11 320.03 850.59 79,157.69 47,390.48
102 5/14/11 316.63 853.99 78,303.70 47,707.11
103 6/14/11 313.21 857.41 77,446.29 48,020.32
104 7/14/11 309.79 860.84 76,585.45 48,330.11
105 8/14/11 306.34 864.28 75,721.18 48,636.45
106 9/14/11 302.88 867.74 74,853.44 48,939.33
107 10/14/11 299.41 871.21 73,982.23 49,238.75
108 11/14/11 295.93 874.69 73,107.54 49,534.68
109
----- 12/14/11
------------- 292.43
---------------- 878.19
---------- 72,229.35 49,827.11
Subtotal:
110 1/14/12
3,737.04
288.92
10,310.42
881.70
72,229.35
71,347.64
49,827.11
50,116.02
Interest Principal Principal Interest
~## Date This Period This Period New Balance To Date
111 2/14/12 285.39 885.23 70,462.41 50,401.41
112 3/14/12 281.85 888.77 69,573.64 50,683.26
113 4/14/12 278.29 892.33 68,681.31 50,961.56
114 5/14/12 274.73 895.90 67,785.42 51,236.28
115 6/14/12 271.14 899.48 66,885.94 51,507.43
116 7/14/12 267.54 903.08 65,982.86 51,774.97
117 8/14/12 263.93 906.69 65,076.17 52,038.90
118 9/14/12 260.30 910.32 64,165.85 52,299.21
119 10/14/12 256.66 913.96 63,251.89 52,555.87
120 11/14/12 253.01 917.61 62,334.28 52,808.88
121 12/14/12 249.34
----- 921.28
----------------- 61,412.99
-- 53,058.21
-
------------------
Subtotal: ----------
3,231.11 10,816.35 61,412.99 53,058.21
122 1/14/13 245.65 924.97 60,488.02 53,303.87
123 2/14/13 241.95 928.67 59,559.35 53,545.82
124 3/14/13 238.24 932.38 58,626.97 53,784.05
125 4/14/13 234.51 936.11 57,690.86 54,018.56
126 5/14/13 230.76 939.86 56,751.00 54,249.33
127 6/14/13 227.00 943.62 55,807.38 54,476.33
128 7/14/13 223.23 947.39 54,859.99 54,699.56
29 8/14/13 219.44 951.18 -53,908.81 54,919.00
X30 9/14/13 215.64 954.99 52,953.82 55,134.63
131 10/14/13 211.82 958.81 51,995.01 55,346.45
132 11/14/13 207.98 962.64 51,032_.37 55,554.43
133 12/14/13 204.13
------ 966.49
----------------- 50,065.88
---------------- 55,758.56
--------------
------------------
Subtotal: ---------
2,700.35 11,347.11 50,065.88 55,758.56
134 1/14/14 200.26 970.36 49,095.52 55,958.82
135 2/14/14 196.38 974.24 48,121.28 56,155.21
136 3/14/14 192.49 978.14 47,143.15 56,347.69
137 4/14/14 188.57 982.05 46,161.10 56,536.26
138 5/14/14 184.64 985.98 45,175.12 56,720.91
139 6/14/14 180.70 989.92 44,185.20 56,901.61
140 7/14/14 176.74 993.88 43,191.32 57,078.35
141 8/14/14 172.77 997.86 42,193.46 57,251.11
142 9/14/14 168.77 1,001.85 41,191.61 57,419.89
143 10/14/14 164.77 1,005.86 40,185.76 57,584.65
144 11/14/14 160.74 1,009.88 39,175.88 57,745.40
145 12/14/14 156.70 1,013.92
---------------- 38,161.96
---------------- 57,902.10
--------------
------------------
Subtotal: ---------------
2,143.54 -
11,903.92 38,161.96 57,902.10
146 1/14/15 152.65 1,017.97 37,143.99 58,054.75
147 2/14/15 148.58 1,022.05 36,121.94 58,203.32
X48 3/14/15 144.49 1,026.13 35,095.81 58,347.81
X49 4/14/15 140.38 1,030.24 34,065.57 58,488.20
150 5/14/15 136.26 1,034.36 33,031.21 58,624.46
Interest Principal Principal Interest
~## Date This Period This Period _ New Balance To Date
151 6/14/15 132.12 1,038.50 31,992.71 58,756.58
152 7/14/15 127.97 1,042.65 30,950.06 58,884.55
153 8/14/15 123.80 1,046.82 29,903.24 59,008.35
154 9/14/15 119.61 1,051.01 28,852.23 59,127.97
155 10/14/15 115.41 1,055.21 27,797.02 59,243.38
156 11/14/15 111.19 1,059.43 26,737.59 59,354.56
157 12/14/15 106.95
-- 1,063.67
--------------- 25,673.91
----- 59,461.51
-----------------
Subtotal: ------------
1,559.41 12,488.05 25,673.91 59,461.51
158 1/14/16 102.70 1,067.93 24,605.99 59,564.21
159 2/14/16 98.42 1,072.20 23,533.79 59,662.63
160 3/14/16 94.14 1,076.49 22,457.30 59,756.77
161 4/14/16 89.83 1,080.79 21,376.51 59,846.60
162 5/14/16 85.51, 1,085.12 20,291.40 59,932.10
163 6/14/16 81.17 1,089.46 19,201.94 60,013.27
164 7/14/16 76.81 1,093.81 18,108._13 60,090.08
165 8/14/16 72.43 1,098.19 17,009.94 60,162.51
166 9/14/16 68.04 1,102.58 15,907.36 60,230.55
167 10/14/16 63.63 1,106.99 14,800.36 60,294.18
168 11/14/16 59.20 1,111.42 13,688.94 60,353.38
69 12/14/16 54.76
-- 1,115.87
--------------- 12,573.08
---------------------- 60,408.14
------------
-
Subtotal: ------------
946.62 13,100.84 12,573.08 60,408.14
170 1/14/17 50.29 1,120.33 11,452.75 60,458.43
171 2/14/17 45.81 1,124.81 10,327.94 60,504.24
172 3/14/17 41.31 1,129.31 9,198.63 60,545.55
173 4/14/17 36.79 1,133.83 8,064.80 60,582.35
174 5/14/17 32.26 1,138.36 6,926.44 60,614.60
175 6/14/17 27.71 1,142.92 5,783.52 60,642.31
176 7/14/17 23.13 1,147.49 4,636.03 60,665.44
177 8/14/17 18.54 1,152.08 3,483.96 60,683.99
178 9/14/17 13.94 1,156.69 2,327.27 60,697.92
179 10/14/17 9.31 1,161.31 1,165.96 60,707.23
180 11/14/17 4.66 1,165.96
--------------- 0.00
-------- 60,711.90
-----------------
Subtotal: --------------
303.76 12,573.08 0.00 60,711.90
-----
Total ------------
payments: --------------
210,711.90 ---------------
Principal: -------
150,000.00 Interest:
60,711.90
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LISTENING IS JUST THE BEGINNING.s°
February 4, 2011
Persun & Heim, P.C.
Attorneys at Law
P.O. Boa 659
Mechanicsburg, PA 17055
Dear Ms. Wetzel,
P.E: fobcrt ~. IJess, deceased D:,cember 11, 2010
In response to your recent inquiry concerning the accounts maintained in the name of
the decedent, please be advised that the following account was open at the date of death:
Money Market #9904-88613 Date of death balance $1,887.33 plus $0.09 accrued
interest, opened 8/28/07,
titled in his name alone with Betty J. Sollenberger
as Power of Attorney
If you have any other questions, please feel free to contact me at (717) 291-2436.
Sincerely,
~~
Joshua A. Groff
Credit Confirmation Processor
This 'v,~!~~`'1 i~ furnish ~ ~. ma.4t~ a' k~u°,ir:~~s c~, !rt~y
~~a~: ~ p:n,~' i4~utr~~', ar;~ is for y%Y !r ~~nf~~~;~4i~' u:*r; c~~ly.
Thy hE~ni~ fs,!;g-i~ilin~ this in:~~;tr~laElc~n dk:~.~ rr~: r•,;,,~,.:n~ ar
~urarar;t>~v $i~!£4 L~'~:1!ri~,G,', C~,iiji~t'~~1E;3F (p;~ ~'~,~!i~~;lit~' ~f 4x18
~ ' r!3F•r;:~:ri!;;i.::S~l^E E8 l,t~?:.lCn~~u 4Tt~ tft>v
inlorrll%.i~~n ~r~i9 `F~~' i,"~
.L~~ ..;~ E~~. ~~,~,k:~ ~x~ ~ ~. ~;z~i its. ~-,ny o~~inicn
~Gn~ ~~ Lri~y nt rl~i C;1(;r~_ i- Y
herein 8x resseG is ~.ut;-~;%4 tc cr~~n~:; vvithcut notic8
1.800.FULTON.4 fultonbank.com
Fulton Bank, N.A. Member FDIC. Member of the Fulton Financial Family.
S~as~ue~~~~
Susquehanna Bancshares, Inc.
February 18, 2011 26 North Cedar street
P.O. Box 1000
Lititz, PA 17543-7000
Tel 1.800.311.3182
Fax 717.625.4478
JENNIFER DENCHAK WETZEL, ESQUIRE
PO BOX 659
MECHANICSBURG, PA 17055-0659
RE: Robert K. Hess Estate
DOD: 12/11/10
SS#: XXX-XX-8015
To Whom It May Concern:
In response to your letter of January 31, 2011, here is the above customer account information
as of December 11, 2010.
• Account Title:
• Account Type/#
• Date Opened /Maturity
Account # 1
Robert K Hess
Ckg/1523838501
6/16/97
• Interest Rate: .00
• Account Balance*: 4,415.16
• Accrued Interest: .00
• YTD Interest: .00
*Account balance does not include accrued interest.
Account #2 Account #3
Robert K Hess
CD/1523838532
5/9/02 / 3/9/12
3.90%
3,000.00
.64
] 17.00
^ There is no safe deposit box in the name of the decedent.
® There is a safe deposit box # 1150712 in the name of the decedent located at the Quarryville Branch.
The box was closed on 2/17/1 1.
Betty Jane Sollenberger was named POA in 2003.
~~-
If I can be of further assistance, please feel free to call.
Sincerely,
~~, ~ ,
Dawn M Berrier
Deposit Research -Reporting Department Lead
1-717-625-6546
DMB/LJR
~_
S ~~ ~~~~~
December 1, 2010
Mr. Robert Hess
222 Messiah Circle
Room 028-D
Mechanicsburg, PA 17055
Dear Mr. Hess:
Continuing Care Retirement Services -Founded 1896
I am writing to you concerning the refund due for the cottage you occupied at 517 Cherry Circle,
Messiah Village.
The acquisition fee paid for the unit in October 2003 was $99,300.00. The agreement was
terminated November 29, 2010. The acquisition fee was amortized over 86 months leaving a
refund in the amount of $13,902.00 (see enclosed amortization schedule).
The payment of the refund will take place upon acquisition of th~unit by another resident.
If you have any questions regarding the refund, please call me at (717) 591-7204.
Sincerely, _
~~° ~'~ Cl1 ~1C~ (..tl~'1
~~~
Michele Ma lich Bros
g
Director of Financial Operations
Encl.
100 Mt. Allen Drive ~ Mechanicsburg, PA 17055-6100
(717) 697-4666 Fax (717) 790-8200 www.messiahvillage.org
I~~~.~~Il~~ ~~
Please'comple~e~a>'aY~~~eas,~;~~~:'
~
Messian~ Village y ._ _
Schedule of Entrance Fee Amortization
'
~ - ~$ase~i;nr, ~
Resident Name ~,~'
Ff ob~rt e~~s~
r ~_._ ~ -. n ~ ., #
Settlement Date
Sz
gten~bet~19,;2D03~ dd
_~ i
~ o.
~ortization Start Date -~~'~ bA
~ Total Entran ce Fee 99,300
il Entrance Fee $ 99,300
rcefund Percentage
_
` ' . .. - 8
Base Refund $ -
Amortized Portion $ 99,300
Unamortized Unamortized Amount Unamortized Unamortized Amount
t
D Balance Percentage Refunded Month Date Balance Percentage Refunded
Month e
a 307
98 99.000% 98,307.00 51 Dec-07 48,657 49.00% 48,657.00
1 Oct-03 ,
314
97 98.00% 97,314.00 52 Jan-08 47,664 48.00% 47,664.00
2 Nov-03 ,
321
96 '97.00% 96,321.00 53 Feb-08 46,671 47.00% 46,671.00
3 Deo-03 ,
328
95 96.00% 95,328.00 54 Mar-OS 45,678 46.00% 45,678.00
q Jan-04 ,
335
94 95.00°% 94,335.00 55 Apr-D8 44,685 45.00% 44,685.00
5 Feb-04 ,
342
93 94.00% 93,342:00 56 May-D8 43,692 44.00% 43,692.00
g Mar-04
4 ,
349
92 93.00% 92,349.00 57 Jun-08 42,699 43.00% 42,699.00
7 Apr-0 ,
356
91 92.00% 91,356.00 58 Jul-OS 41,706 42.00% 41,706.00
Ma 04 ,
363
90 91.00°% 90,363.00 59 Aug-OS 40,713 41.00% 40,713.00
g Jun-04 ,
370
89 %
90 OD: ..89,3.0.00 - 60 Sep-08 39,720 40.00% - 39,72-0.00 -_
10 Jui-04 ,
377
88 o
89.00% 88,377.00 61 Oct-08 38,727 39.00% 38,727.00
11 Aug-04 ,
384
87 88:00% 87,384.00 62 Nov-08 37,734 38.00% 37,734.00
12 Sep-04
4 ,
391
86 87.00% 86,391.00 63 Dec-08 36,741 37.00% 36,741.00
13 Oct-0
4 ,
398
85 86.000% 85,398.00 64 Jan-09 35,748 36.00% 35,748.00
14 Nov-0
4 ,
405
84 85.00 /0 84,405.00 65 Feb-09 34,755 35.00% 34,755.00
15 Dec-0
5 ,
412
83 84.00% 83,412.00 66 Mar-09 33,762 34.00% 33,762.00
16 Jan-0 ,
419
82 83.00% 82,419.00 67 Apr-09 32,769 33.00°!0 32,769.00
17 Feb-05 ,
426
81 82.000% 81,426.00 68 May-09 31,776 32.00% 31,776.00
1 g Mar-05 ,
433
80 81.00% 80,433.00 69 Jun-09 30,783 31.00% 30,783.00
1g Apr-05 ,
440
79 80.00% 79,440,00 70 Jul-09 29,790 30.00% 29,790.00
20 May-05 ,
447
78 79.00% 78,447.00 71 Aug-09 28,797 29.00% 28,797.00
21 Jun-05 ,
454
77 78.00% 77,454.00 72 Sep-09 27,804 28.00% 27,804.00
22 Jul-05 ,
461
76 77.00% 76,461.00 73 Oct-09 26,811 27.00% 26,811.00
23 Aug-05 ,
468
75 76.00% 75,468.00 74 Nov-09 25,818 26.00% 25,818.00
~4 Sep-05 ,
475
74 75.00% 74,475.00 75 DeG09 24,825 25.00% 24,825.00
25 O~-05
Nov-05 ,
482
73 74.00% 73,482.00 76 Jan-10 23,832 24.00% 23,832.00
28 Dec-05 ,
72
488 73.00% 72,489.00 77 Feb-10 22,839 23.00% 22,839.00
27 Jan-06 ,
496
71 72.00% 71,496.00 78 Mar-10 21,846 22.00% 21,846.00
28 Fei~06 ,
503
70 71.00% 70,503.00 79 Apr-10 20,853 21.00% 20,853.00
gg
- ar.~6 ,
510
69 70.00% 69,510.00 80 May-10 19,860 20.00% 19,860.00
~. Ap;=f36 ,
68,517 69.00% 68,517.00 81 Jun-10 18,867 19.00% 18,867.00
2 ay_O6 67,524 68.00% 67,524.00 " 82 Jrl-10 17,874 18.00% 17,874.00
3 Jun-06 531
66 67.00% 66,531.00 83 /dug-10 16,881 17.00% 16,881.00
3 lu{~ ,
538
65 66.00% 65,538.00 84 Sep-10 15,888 16.00% 15,888.00
~
35 ,
Aug-06 ,
64,545 65.00% 64,545.00 85 Oct-10 14,895 15.00% 14,895.00
J
36 Sep-06 63,552 64.00% 63,552.00 86 Nov-1D 13,902 14.00% 13,902.00
'---
Oct-O6 - 559
- 62 63.00% -52,359.00 $7 - Deo-10 12,909 13.00% 12;909:00
___._37_. -_ _ Nov-06 ,
566
61 62.00% 61,566.00 88 Jan-11 11,916 12.00% 11,916.00
38 Dec-06 ,
573
60 61.00% 60,573.00 89 Feb-11 10,923 11.00% 10,923.00
3g Jan-07 ,
580
59 60.00% 59,580.00 90 Mar-11 9,930 10.00% 9,930.00
40 Feb-07 ,
587
58 59.00% 58,587.00 91 Apr-11 8,937 9.00% 8,937.00
41 iar-07
t ,
594
57 58.00% 57,594.00 92 May-11 7,944 8.00% 7,944.00
42
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Apr-07 ,
56,601 57.00% 56,601.00 93 Jun-11 6,951 7.00% 6,951.00
44 ly;ay-07 55,608 56.00% 55,608.00- .94 Jul-11 5,958 6.00% 5,958.00
n-07
J 615
54 55.00% 54,615.00 95 Aug-11 4,965 5.00% 4,965.00
45
46 u
Jug-07 ,
53,622 54.00% 53,622.00 96 Sep-11 3,972 4.00% 3,972.00
47 Aug-07 52,629 53.00% 52,629.00 97 Oct-11 2,979 3.00% 2,979.00
48 Sep-07 51,636 52.00% 51,636.00 98 Nov-11 1,986 2.00% 1,986.00
4g Oct-07 50,643 51.00% 50,643.00 99 Dec-11 993 1.00% 993.00
50 Nov-07 49,650 50.00% 49,650.00 100 Jan-12 (0) 0.00% (0.00)
RA~'1VIOND A1~~SG
FINANCIAL SER~/ICES INC.
Member NASD /SIP C
December 14, 2010
Gary J. Heim, Esq.
Persun & Heim, P.C.
P.O. Box 659
Mechanicsburg, PA 17055-0659
Re: Robert K. Hess
Raymond James Account # 82539400
Kemper Scudder Destinations Annuity Contract KI11041924
Dear Attorney Heim;
Jay W. Charles, M.B.A., C.I.M.A.
Investment Consultant
Eric C. Peinhardt
Financial Advisor
Scott E. Bauermaster
Financial Advisor
Please extend our deepest sympathies to the family in the loss of Mr. Hess.
Attached please find an Unrealized Gain and Loss report for Mr. Hess's Raymond James
account as per his date of death, December 11, 2010. An Account Information and Client
Agreement is also attached to transfer his account to an Estate Account. The Executor/s
will have to complete the highlighted areas and sign where indicated. We will also need
an original Letter of Administration.
Also, be advised that his Kemper Scudder Destination Annuity contract value as of close
on Friday, December 10, 2010 was $26,980.81. As per Kemper Annuities, Richard Hess
and Betty Sollenberger are beneficiaries of the annuity contract, 50% each.
Attached please find the Claim Forms to be completed by each Richard and Betty. A
certified death certificate is also required.
Thank you Attorney Heim, and if we can be of any further assistance, please feel free to
contact us at 717-464-0100.
Sincerely,
Jill D. Groff
Administrative Assistant
Raymond James Financial Services
208 Willow Valley Square, Lancaster, PA 17602
717.464.0100 Fax: 717.464.2979
a
ZI~RICI-I
ZURICH AMERICAN LIFE INSURANCE COMPANY
SERVICE CENTER
PO Box 19097
February 16, 2011 GREENVILLE, SC 29602-9097
USA
(1\/FRNIRHT Qf111RFSS:
Betty Sollenberger
856 Kirkwood Pike
Quarryville, PA 17566
~^ RE: Robert K Hess, Deceased
Contract No: KI11041924
Claim No: CLl 1041924
Dear Ms. Sollenberger,
2000 WADE HAMPTON BLVD
GREENVILLE, SC 29615-1064
USA
TOLL-FREE
1.800.449.0523
www.wrichamericanlifeinsurance.com
Enclosed is our check representing full and final settlement on the above-mentioned contract. The total value of the
claim was determined as shown:
Contract Value at Date of Death + $ 26,980.81
(_ or- dzre proof on some variable contracts)
Total Indebtedness Repaid - $ 0.00
Surrender Charge (rf applicable) : - $ 0.00
_ v
Total Death Benefit - $ 26,980.81
As b~ueficiat~: you are e~itled to 50 percent of the total death benefit_ The value was determined as follows:
Your Share of the Death Benefit
Plus Interest Payable from the + $ 13,490.41
-'I'-ermi~z~Tion ate to aynient + $~
Taxes Withheld - $ 285.04
Total Chsrck Amount _ $ 13,212.02
n ..~~ $ ~,~ ~ ~-~ ~ p.,~ at the end of the calendar year. The Social Security /Tax Identification No. of
- ,~~ ~-~,_~ ~-~ -_~~ _ Tla~ zoal mount to be shown as taxable is 52,857.05. Should you have any questions
`_ . =, ~_ _; W,==-z- p~e~ •,c~;;;a,::t our Customer Sen~ice Deparhnent directly. Our telephone number is
~~~~ -
c;.: ~ ~" Chari~:'S E Bauermaster
=;~ ~i gltoR- ~~alley Square
Lancaster, PA 17602
ZA0;750-1521004 [CLAIMS] AFINB
FINAL SETTLEMENT TO BENEFICIARY
t'
ZURICH
ZURICH AMERICAN LIFE INSURANCE COMPANY
SERVICE CENTER
PO Box 19097
February 16, 2011 GREENVILLE, SC 29602-9097
USA
OVERNIGHT ADDRESS:
Richard Hess
862 Kirkwood Pike
Quarryville, PA 17566
2000 WADE HAMPTON BLVD
GREENVIILE, SC 29615-1064
USA
TOLL-FREE
1.800.449.0523
www zurichamericanfifeinsurance.com _ . _
RE: Robert K Hess, Deceased
Contract No: KI11041924
Claim No: CL11041924
Dear Mr. Hess,
Enclosed is our check representing full and final settlement on the above-mentioned contract. The total value of the
claim was dete>:mi~aed as shown:
Contract Value at Date of Death + $ 26,980.81
(or due proof on some va;'iable contracts)
Total Indebtedness Repaid - $ 0.00
Surrender Charge (f applicable) - $ 0.00
Total Death Benefit _ $ 26,980.81
~; r; -x~~.-~. z-ou are entitled to 50 percent of the total death benefit. The value was determined as follows:
Your Share of the Death Benefit
Plus Interest Payable from the + $ 13,490.41
-- - - -- --- er on a e o aymen .--~._-~-6~~
Taxes Withheld : - $ 285.04
- Total Check Amoant _ $ 13,212.02 ~
- -~ ~~~.~ ~_=-e ~ „a - ;o:;,fi }~ ~ ai the end of the calendar year. The Social Security /Tax Identification No. of
~,;,_~-~ ~~_~ 3~~1. T :. total ama~.mt t®be shown as taxable is $2,857.05. Should you have any questions
_ y ~_ ~ ;,~ _'=;~~ please contact oar Customer Seance Department directly. Our telephone number is
,~}~
_ t ~~.-~ ~_._._.-
~~::~~a:
C' =; r~ Seance Center
cc: J tiV Charles/S E Bauermaster
'?08 Willow Valley Square
Lancaster, PA 17602
ZA0050-1521004 (CLAIMS] AFINB
FINAL SETTLEMENT TO BENEFICIARY
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10D MOUNT ALLEN DRIVE, MECHANICSBURG, PA 17055
BETTI' SOLLE!~BERGER
856 KIRh'V~'OOD PIKE
QL e,RR~'~'II..LE, PA 17566
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Form PB-01
DATE DESCRIPTION
Balance Forward
I? "31 °?010PA~~v~N-T' RECEI«D - TH.4:\'i~ ~'Oti:,,,
12b31G2010~ ~i~DICARF PART A CO-LNSL~2ANCE
;:12;3162010 HEALTH SHAKES SUGAR FREE
*** Nursing Care ***
11/20/2010 WATCH MATE BRACELET
12!01/2010 MOTION MONITOR 12/01-12/10
12/01/2010 WATCH MATE MONITORING 12/01-12/10
- #111 _
1.2/10/2010 RlYi/ BRD -NURSING -SEMI-PVT
12/01-12/10
12/10/2010 OXYGEN 12/O1-12/04
12I10/2D10 A IR MATTRESS 12/01-12/04
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RESIDENT# UNIT STMT._DATE
90310 028 D 12/31/2010
RESIDENT S
Mr. ROBERT K. HESS
TOTAL AMOUNT DUE $77.15
DATE DUE 01/31/2011
RATE
165.00 1.00
1.61 1.00
1.29 10.0(
299.00 10.0(
17.50 4.00
4.00 4.00
CHARGES CREDITS BALANCE
10,582.84
13,902.00 -3,319.16
450.00 -2,869.16
.20.80 -2,848.36
165.00 -3,013.36
1.61 -3,011.75
12.90 -2,998.85
2,990.00 -8.85
70.00 61.15
16.00 77.15
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RESIDENT # CURRENT OVER 30 OVER 60 OVER 90 OVER 120 TOTAL AMOUNT DUE
90310 ..77.15.. 0.00 0.00 0.00 0.00 $77.15
Form PB•Ot
RESIDENT NAME Mr. ROBERT K. HESS
Please make check payable to Messiah Village.
~ 1% finance charge may be assessed on accounts for which payment has not been received b}~ the due date. Thank you!
If you have any questions or concerns about your bill, please address them directly to Fiscal Services at 790-8220. Thank You!
LLOYD R. PERSUN
GARY J. HEIM
MATTHEW E. HAMLIN*
VICKY ANN TRIMMER**
JENNIFER DENCHAK WETZEL
*ALSO NEW YORK BAR
** ALSO A CPA
Register of Wills
Cumberland County Courthouse
1 Courthouse Square, Room 102
Carlisle, PA 17013
Re: Estate of Robert K. Hess
File No.: 21-10-1260
Dear Sir/Madam:
Enclosed for filing are the following:
July 11, 2011
[RS NO. 26-3786257
(717)620-2440
FAX: (717) 620-2442
jdwetzel@persunheim.com
VIA CERTIFIED MAIL
RETURN RECEIPT REQUESTED
1. Original and one copy of an Inventory;
10904.0001
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2. Original and one copy of a Pennsylvania Inheritance Tax Return, along with a copy of the
cover page of the tax return;
3. A check payable to "Register of Wills, Agent" in the amount of $569.00 in payment of the
balance of Inheritance Tax owed;
4. A check in the amount of $30.00 for additional probate fees; and
5. Aself-addressed, postage prepaid envelope for return mail.
Please file the original Inventory and Inheritance Tax Return. Please forward a copy of the
Inheritance Tax Return to the Pennsylvania Department of Revenue. Please return adate-stamped copy
of the Inventory and the cover page of the tax return to my attention in the enclosed envelope, along with
a receipt for the Inheritance Tax payment.
Please do not hesitate to call with any questions. Thank you for your assistance.
Very truly yours,
JDW:dgh
Enclosures
cc: Betty Sollenberger (w/ enclosures)
Richard Hess (w/o enclosures)
Persun & Heim, P.C.
Attorneys at Law
1700 Bent Creek Boulevard
Suite 160
Mechanicsburg, PA 17050
Please reply to:
PO Box 659
Mechanicsburg, PA 17055-0659
HTTP://W W W.PERSUNHEIM.COM
~~
fifer Denchak Wetzel
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