Loading...
HomeMy WebLinkAbout03-0539REAGER & ADLER, P.C. BY: LINUS E. FENICLE, ESQUIRE Attorney I.D. No. 20944 2331 Market Street Camp Hill, PA 17011 (717) 763-1383 Attorney for Petitioner IN RE: RALPH C. GUNDRUM IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY ORPHANS COURT DIVISION PETITION FOR THE APPOINTMENT OF A PLENARY GUARDIAN OF THE PERSON AND ESTATE OF RALPH C. GUNDRUM AND NOW, comes the Petitioner and proposed guardian, Diane Haines, by and through her counsel, Reager & Adler, P.C. and respectfully represents the following: 1. The name and address of the Petitioner is Diane Haines, an adult individual residing at 213 South Bellevue Avenue, Langhome, Pennsylvania 19047. The Petitioner is Diane Haines, daughter of Ralph C. Gundmm and Power of Attomey for Ralph C. Gundmm. 2. Ralph C. Gundmm (herinafter "Gundmm"), is a 77 year old individual currently residing in the Manor Care Facility, 940 Walnut Bottom Road, Carlisle, Pennsylvania 17013. Diane Haines 533 W. Maple Avenue Langhorne, P A 19047 215-752-3338 June 4, 2007 Cumberland County Court of Common Pleas A TTN: Orphan's Court Cumberland County Courthouse 1 Courthouse Square Carlisle, PA 17013-3387 Re: IN RE: RALPH C. GUNDRUM NO.: 21-2003-0539 Orphans Court Division Dear Sir or Madam: I was the Guardian for my father, Ralph C. Gundrum, in the above-captioned matter. My father died on April 1, 2007. Enclosed please find a final accounting of his financial accounts, from the last report until his death, and a filing check for $15.00. Please contact me at the above address or by telephone at 215-752-3338 with any questions. Sincerely, ~~~ Diane Haines Enclosures - 2 (- r~: I --! c.) f',) \.0 By: Diane Haines Guardian for Ralph C. Gundrum 533 W. Maple Avenue Langhorne, P A 19047 215-752-3338 I ---: ; I ,. ... 1_&....' (.) C' IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY IN RE: RALPH C. GUNDRUM NO.: 21-2003-0539 ORPHANS COURT DIVISION Financial Accountin2 from AU2ust 14" 2006 to Aorill. 2007 Checkbook Activity: 8/14/06 Checkbook Balance: 6,048.93 8/24/06 To: Triangle Travel Store - 120.00 5,928.93 8/24/06 Direct Deposit - August + 1,105.00 7,033.93 Social Security 8/25/06 To: Cumberland County - 15.00 7,018.93 Orphan's Court filing fee 9/6/06 To: Manorcare - 1,065.00 5,953.93 September 9/6/06 To: PNC 25.00 5,928.93 Safe Deposit Box 9/24/06 Direct Deposit-September + 1,105.00 7,033.93 Soc.Sec. 9/24/06 To: Capital Blue Cross 10/1/06-12/31/06 265.29 6,768.64 10/12/06 To: ManorCare October 799.71 5,968.93 ,~ o 10/29/06 Direct Deposit-October + 1,105.00 7,073.93 Social Security 11/8/06 To: ManorCare - 1,065.00 6,008.93 November 11/15/06 Direct Deposit + 1,105.00 7,113.93 November SS 12/11/06 To: ManorCare - 1,065.00 6,048.93 December 12/12/06 Direct Deposit + 1,105.00 7,153.93 December SS 12/17/06 To: Capital Blue Cross - 265.29 6,888.64 1/1/07 to 3/31/07 12/17/06 To: Alan Haines 17.96 6,870.68 clothing for Ralph 12/26/06 To: Diane Haines 37.09 6,833.59 Norelco shaver for Ralph 1/10/07 To: ManorCare 833.71 5,999.88 January 1/12/07 Direct Deposit + 1,139.00 7,138.88 January SS 1/19/07 To: Alan Haines 29.00 7,109.88 tolls - 10/06, 1/07 2/8/06 To: ManorCare 1,099.00 6,010.88 February 2/15/06 Direct Deposit + 1,139.00 7,149.88 February SS 2/27/07 To: Alan Haines 30.00 7,119.88 Shirts for Ralph 3/6/07 To: Manor Care 1,099.00 6,020.88 March 2 " .. 3/25/07 To: Capital Blue Cross 265.29 5,755.59 4/1/07 to 6/30/07 3/25/07 Direct Deposit + 1 ,139.00 6,894.59 March SS 4/1/07 Checking acct. interest + 4.88 6,899.47 8/06 - 4/1/07 4/1/07 Checking acct. deductions 8/06-411/07 41.90 6,857.57 HCR resident trust fund as of + 469.96 7.327.53 Total last statement 3/31/07 3 3. Gundmm has resided there since April 21, 2003, and prior to that lived at 10 East South Street, Franklintown, Pennsylvania, 17323. 4. In March and early April,2003, where Gundrum was hospitalized in Holy Spirit Hospital, Camp Hill, and then sent to rehab prior to moving to the Manor Care Facility. 5. Gundrum's primary care physician is Dr. Darryl Guistwite, 522 South Pitt Street, Carlisle, Pennsylvania, 17013. 6. Gundrum suffers from functional limitations due to dementia. He is in the Arcadia Unit at Manor Care which is the special dementia unit. As a result of his condition, Gundrum has memory loss and is unable to make decisions concerning his well being and financial assets. Gundrum cannot remember people or events that occurred earlier in any given day. Dr. Guistwite has evaluated him and determined he suffers from dementia. 7. Petitioner has been acting as Gundrum's attorney-in-fact under a Power of Attorney A true and correct copy of the Power of Attorney signed by Gundmm on March 28, 2003. is attached hereto as Exhibit "A". 8. Paragraph 25 of Gundrum's Power of Attorney states as follows: "Guardian of the Person and Estate. For the purpose of recording my wishes in a convenient place, I record here that if it is necessary to appoint a guardian of my person or a guardian of my estate, it is my desire that Diane Haines, be appointed." 9. As Gundrum's attorney-in-fact, Petitioner has been managing and overseeing Gundrum's financial affairs and his physical care. 10. Petitioner is a daughter of Gundmm and is 50 years old, and has complete knowledge 2 of Gundmm's estate and physical needs. 11. Petitioner is the most qualified person to serve as guardian for Gundrum since she is his daughter, has complete knowledge of Gundrum's estate and physical needs, and is Gundmm's Power of Attorney. 12. Gundmm also has another daughter, Petitioner's sister, Luane Gundmm, who resides at 1837 North Defiance Street, Tacoma, Washington 98406. Luane Gundrum also has complete knowledge of Gundrum's estate and physical needs and it is the desire of Diane Haines that Luane also be appointed as co-guardian of Gundrum. Petitioner requests that it be ordered that Diane Haines and/or Luane Gundrum would be guardian of Gundmm. 13. Gundmm has indicated in his Power of Attomey that Petitioner is the individual that he desires to be guardian. 14. Petitioner is seeking the appointment as plenary guardian of the person and the estate of Gundmm because she fears Gundmm may be subject to undue persuasion and influence and acts from third parties not acting in Gundmm's best interests. 15. Specifically, a certain former neighbor and landlord has recently been to the Manor Care Facility along with an attorney, and upon information and belief was attempting to have Gundrum revoke the Power of Attorney that he has given to Diane Haines. 16. If appointed guardian, Petitioner can safeguard Gundrum's property for Gundrum's well being and continue to oversee Gundrum's physical care. Petitioner's appointment as guardian should be for an indefinite period of time. 17. heirs. 18. Gundmm has two daughters, Diane Haines and Luanne Gundrum, as his only adult Petitioner's interest is not adverse to Gundrum. 19. The estimated value of Gundmm's estate is Eighty Five Thousand to Ninety Thousand Dollars ($85,000 to $90,000) with his primary assets consisting of certificates of deposit. 20. Gundrum receives social security in the amount of $1,035.00 monthly and also receives the sum of $232.00 monthly for the next two years, which is a payment from the sale of a parcel of real estate. 21. The appointment of Petitioner as plenary guardian is the least restrictive manner by which Gundmm's interests can be protected. 22. No other court has ever assumed jurisdiction in any proceeding to determine the capacity of Gundrum. 23. Petitioner fully understands the duties and responsibilities that would be required of her as plenary guardian of the person and estate of Gundrum. WHEREFORE, Petitioner, Diane Haines, requests this Court to appoint Petitioner and/or her sister, Luane Gundrum, as plenary guardians of the person and estate of Ralph C. Gundrum. Dated: Respectfully submitted, REAGER &.~DLER, P.C~.' Einus E. Fenicle, Esquire Attorney I.D. No. 20944 2331 Market Street Camp Hill, PA 17011 (717) 763-1383 Attorney for Petitioner 4 VERIFICATION I, Diane Haines, verify that the statements made in the foregoing pleading are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904, relating to unsworn falsification to authorities. Date: ~'/~l/~' ~ ~~ Diane Haines EXHIBIT A up~ v~ ~L~mer ~wpwm ~LIr~u S WVlII$\L~U n clrumh(, t-'tJ,~.wpd March 27. 2003 NOTICE REGARDING POWER.OF ATTORNEY THE PUP_POSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON YOU DESIGNATE (YOUR "AGENT") BROAD POWERS TO HANDLE YOUR PROPERTY, WHICH MAY INCLUDE POWERS TO SELL OR OTHERWISE DISPOSE OF ANY REAL OR PERSONAL PROPERTY WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL BY YOU. THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON YOUR AGENT TO EXERCISE GRANTED POWERS, BUT WHEN POWERS ARE EXERCISED, YOUR AGENT MUST USE DUE CARE TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS POWER OF ATTORNEY. YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE THROUGHOUT YOUR LIFEThME, EVEN AFTER YOU BECOME INCAPACITATED, UNLESS YOU EXPRESSLY LIMIT THE DURATION OF THESE POWERS OR YOU REVOKE THESE POWERS OR A COURT ACTING ON YOUR BEHALF TERMINATES YOUR AGENT'S AUTHORITY. YOUR AGENT MUST KEEP 'YOUR FUNDS SEPARATE FROM YOUR AGENT'S FUNDS. THE POWERS AND DUTIES OF AN AGENT UNDER A POWER OF ATTORNEY ARE EXPLAINED MORE FULLY IN 20 Pa.C.S. CH. 56. ~ THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD.ASK A LAWYER OF YOUR OWN CHOOSING TO EXPLAIN IT TO YOU. I HAVE READ OR HAD EXPLAINED TO ME THIS NOTICE AND I UNDERSTAND ITS CONTENTS. RALPH C. GUNDRUM, Principal Date \\Nt. serveADBiller\wpwin\Linus\Wills\GundrumR. POA.wpd March 27, 2003 .GENERAL POWER OF ATTORNEY I, RALPH C. GUNDRUM, hereby appoint DIANE HAINES, (hereinafter referred to as "my agent") my agent for me and in my name and place; provided that if DIANE HAINES, for any reason fails or ceases to act, (determined in the opinion of the successor named as my agent) I appoint LUANE GUNDRUM, to act in place of my ori~nal agent. For the purposes of reliance by third parties, the presentation of this power by the successors named as my, agent shall be deemed conclusive proof that the previous agent has failed to act or ceased to serve. I direct my agent to transact all my business and to manage all my property and affairs as comp!etely as I myself might do if personally present, including but not limited to, exercising the following powers: 1. Execution of Contracts. To enter into, perform, modify, extend, cancel, compro~rfise, enforce, or otherwise act with respect to any contract of any sort whatsoever, including but not limited to Ieases and mortgages, and to pay any money or to transfer title and possession to any real or personal property that may be required to be paid or transferred by any contract or in the performance of any obligation entered into or incurred by me or on my behalf. 2. Investments. To invest in all forms of real and personal property without any restriction whatsoever as to the kind of investment, including, but not limited to, United States Treasury Bonds which are redeemable at par in payment of federal estate taxes. nominee. Registration. of Property. To hold property unregistered or in the name of a 4. Personal Propert35 To buy or sell at public or private sale for cash or credit or partly for each, exchange, Pledge, lease, give or acquire Options for sales or exchanges or leases, or by any other means whatsoever to acquire, dispose of, repair, alter or manage tangible or intangible personal property or any interest therein; and, without limitation, with respect to any securities, to comply with any securities laws or regulations, to execute indemnity a~eements, to purchase insurance and to pay commissions or discounts required by any underxvriting. 5. Real ProperS. To buy or sell at public or private sale for cash or credit or partly for each, exchange, mortgage, encumber, lease for any period of time, give or acquire options for sales, purchases, exchanges or leases, dedicate, or by any other means whatsoever to acquire to dispose of real property or any interest therein; to partition and subdivide real property, to manage real property; to repair, alter, erect, or tear down any structure or part thereof; and to file such plans, applications, or other documents in connection therewith and do such other acts as may be requested by any government or other authority having or purporting to have jurisdiction. 2 \\Ntse rye r\DBiller\wpwin~Linus\Wills\GundrumR. POA.wpd March 27, 2003 of my agent with respect to transactions covered by this power of attorney, My agent shall be subject to whatever bank rules and regulations I would be subject to. I2. Receipts and Approval of Account.~. To receive a payment of any kind, including. a bequest, devise, gift or other transfer of real or personal property to me in my own right or as a fiduciary for another, and to give full receipt and acquittance therefor, or a refunding bond therefor, to approve accounts of any business, estate, trust, partnership or other transaction whatsoever in which ]~ may ha.ye any interest of any nature whatsoever, and to enter into any compromise and release in regard thereto. 13. Compromise and Arbitration of Claims. To compromise or arbitrate any claim in which I may be in any manner interested, and for that purpose to enter into agreements to compromise or arbitrate, and either through counsel or otherwise to carry on such compromise or arbitration and perform or enforce any award entered in arbitration. 14. Institution and Defense of Claim~. To institute, prosecute, defend, compromise, or otherwise dispose of, and to appear for me in, any proceedings at law or in equity or otherwise before any tribunal for the enforcement or for the defense of any claim, either alone or in conjtmction with other persons, relating to me or to any property of mine or any other person (including the authority to sue if this power of attorney is not honored), and to retain, discharge and substitute counsel and authorize appearance of such counsel to be entered for me in any such action or proceeding. 15. Taxes. To prepare, execute and file in my name and on my behalf any return, report, protest, application for correction of assessed valuation of real or other property, appeal, brief, claim for refund, or petition, including petition to the United States Tax Court, in connection with any tax imposed or purported to be imposed by any government, authority or agency, or claimed, levied or assessed by any government, authority or agency and to pay any such tax and to obtain any extension of time for any of the foregoing; to execute waivers of restrictions on the assessment and collection of deficiency in any tax; to execute closing agreements and all other documents, instruments and papers relating to any tax hability of mine of any sort; to institute and carry on either through counsel or otherwise any proceeding in connection with contesting any such tax or to recover any tax paid, or to resist any claim for additional tax or any proposed assessment or levy thereof, and to enter into any agreements or stipulations for compromise or other adjustment or disposition of any tax. 16. Disclaimer. To execute, deliver and file or record disclaimers of any part or all of any property, power or interest passing to or for me under any will, deed of trust or otherwise; and to direct my spouse's executor to elect to qualify or to elect not to qualify for the marital deduction any portion or all of a marital deduction trust created for me by my spouse. 17. Employment of Others. To employ accountants, agent, investment counsel, custodians, agents, servants, and others, and to delegate to them, to remove them, and to pay them such remuneration as my agent shall deem proper. \\N tserver\DBiller~wpwin%inus\Wills\Gundru m R.POA.wpd March 27, 2003 18. _Execution of Documents. To execute, deliver,' file for record, cancel, modify, enforce, acquire or dispose of any instrument including, but not limited to, stock and bond powers, vehicle registrations, financing statements and related filing documents, reports of any sort to any government, authority or agency, as required or permitted by law, deed with or without covenants or warranties, and any other document appropriate for carrying out any of the foregoing powers. 19. ..Revocable Trust To Be Created. To execute any revocable deed of trust on my behalf under the terms of which (i) nay agent or any one or more other persons or corporations with fiduciary powers selected by my agent is named as the trustee or Ixustees, (ii) during my lifetime the entire net income and as much of the principal as I, my agent or my trustee thinks desirable shall be paid to me or for my benefit (including those I am legally obligated to support), and (iii) upon my death the principal and any undistributed income shall be payable to the executor or admirfistrator of my estate; and to transfer property to the trustee or trustees thereunder. 20. Revocable Trusts Previously Created. To deliver any property of mine to and deposit any such property with the trustee or trustees of any revocable deed of trust executed by me for my benefit even though the trust may not be payable upon my death to my estate and to revoke in whole or in part any such trust. 21. GiftS. To give property without consideration in any amount for and on my behalf to any donees (including my agent), outr/ght or in trust, so long as my agent believes that after such gifts sufficient funds will remain to provide for m.y welfare. 22. Continuation of Gift Program. To continue any program of gifts that I may have begun by giving property withou~ consideration to persons, including my agent, outright or to trusts which I have previously created for their benefit. I give my agent this power because it is my intention that my giving program can be continued in the event of my disability. However, in no event shall any m-nounts be given to my agent or to chscharge a legal obligation of my agent which in the aggregate total more than 5% of my estate per year. 23. Payment of Fees to My Agent compensation for services rendered hereunder. My agent shall be entitled to reasonable 24. Placement in an Institution. To take charge of my person in case of illness or disability of any kind; to authorize my admission to a medical, nursing, residential or similar facility, and to enter into agreements for my'care; and to remove and place me in such institutions or places as my agent may deem best for my personal care, comfort, benefit and safety after giving consideration to any wishes I have previously expressed on this subject. 25. Guardian of the Person and Estate. For the purpose of recording my wishes in a convenient place, I record here that if it is necessary to appoint a guardian ofmyperson or a g~ardian of my estate, it is my desire that DIANE HAINES, be appointed. \\Ntserver\DBiller\wpwin\Lin us\Wills\GundrumR.POA.wpd March 27, 2003 26. my spouse. Elective Share. To claim an elective share of the estate of my spouse, if I survive 27. Renounce Fiduciary Positions. To renounce fiduciary positions to which I have been appointed or am serving. 28. Renounce Political Positions, To renounce political offices to which I have been appointed, elected or am serving. 29. Withdraw Trust Funds. To withdraw and receive the income or corpus of any trust over which I have a power of withdrawal. 30. Termination of Appointment as My Agent. My agent's appointment hereunder shall terminate by operation of law or upon (i) delivery to me of my agent's ~vritten resignation or (ii) delivery to my agent of a written revocation of this power signed by me, and my agent may request the written opinion of a licensed physician stating that in his or her opinion I am not an' "incompetent" as Qzat word is defined in 20 Pa.C.S. Section 5501. Upon termination my agent shall return to my full control any property of mine in my agent's possession within a reasonable thrte consistent with an orderly transfer thereof. My agent's deposit of funds or intangible or tangible personal property in accounts or safe deposit boxes titled' in my name alone at any bank, trust company, savings and loan institution, brokerage firm or depository shall, after notice to me of such deposit, constitute return to my full control, and my agent shall have no further responsibility for funds so deposited. 31. Successor Agent. My agent acting as successor agent shall not be obliged to examine any accounts, records or acts of the previous agent, nor shall any successor in any way or manner be responsible for any act or omission to act on the part of any previous agent. 32. General. To do all things which my agent shall deem proper in order to carry out any of the foregoing enumerated powers, which shall be construed in the broadest possible .manner. In no event shall my agent take any action concerning a policy of insurance on my agent's life. The descriptive headings of this general power of attorney are inserted for convenience only and shall not be deemed to affect the meaning or construction of any. of the provisions hereof or to limit in any way the construction thereof in the broadest possible manner. 33. Substitution. My agent shall have full power of substitution and revocation, and such substitution or revocation may relate to, or be limited to, any one or more or ali oft. he foregoing acts or po~vers, or be limited as to time or in such other respect as my agent shall deem proper. 34. Ratification. I hereby ratify and confirm all that my agent or the substitute or substitutes therefor shall Iawfully do or cause to be done by virtue hereof. 35. Reliance by Others. This power of attorney shall continue in force and may be accepted and rehed upon by anyone to whom it is presented despite my purported revocation of this \\Ntserver~DBiller\wpwin\Linus\Wills\GundrumR.POA.wpd March 27, 2003 power, the age of this power, the issuance ora court decree declaring my incompetency or my death, until written notice of such event is received by such person. 36. disability or incapacity. Effect of My Disability. Executed on this 2,8'/ day of //~(c~-~-z ,2003. RALPH C. GUNDRUM This power of attomey shall not be affected by my COMMONWEALTH OF PENNSYLVANIA ) · SS: COUNTY OF CUMBERLAND ) Onth ., 2003, before me the undersigz~ed officer, personally appeared RALPH C. GUNDRUM, known to me (or satisfactorily proven) to be the person whose name is subscribed to the foregoing instrument, and ackno~vledged that he executed it for the purposes therein contained. WITNESS my hand and official seal the day and year aforesaid. Notary P~lic [3~-. ~ ........ :.'.~0', ~,cnlr~"S tk~l~- !5, ~O0~i j 7 \\Ntse rver\DBiller~wpwin~Linus\Wills\GundrumR,POA.wpd March 27, 2003 ACKNOWLEDGMENT BY AGENT I, DIA_NE HAINES, 'have read the attached Power of Attomey and am the person identified as the agent for the principal. I hereby acknowledge that in the absence of a specified provision to the contrary in the Power of Attorney or in 20 Pa.C.S. when I act as agent: shall exercise the powers for the benefit of the principal. I shall keep the assets of the principal separate from my assets. I shall exercise reasonable caution and prudence. I shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the principal. DIANE HAINES, Agent Date COMMONWEALTH OF PENNSYLVANIA ) · SS: COUNTY OF CUMBERLAND ) Onthis~,~~ dayof ~ff~./t.4~-~ ,2003, before me the undersigned officer, personally appeared DIANE FIAINES, known to me (or satisfactorily proven) to be thc person whose name is subscribed to the foregoing instrument, and acknowledged that she executed it for the purposes therein contained. WITNESS my hand and official seal the day and year aforesaid. g' [:[[~ [- 'iR,r'' ~'0. REAGER & ADLER, RC. A'I-I'ORNEYS AT LAW 2331 MARKET STREET CAMP HILL, PA 17011-4642 (717) 763-1383 REAGER & ADLER, P.C. BY: LINUS E. FENICLE, ESQUIRE Attorney I.D. No. 20944 2331 Market Street Camp Hill, PA 17011 (717) 763-1383 Attorney for Petitioner IN RE: RALPH C. GUNDRUM JU O0 2OO3 IN THE COURT OF COMI~N PLEAS CUMBERLAND COUNTY ~ ' ORPHANS COURT DIVISION PRELIMINARY DECREE AND NOW, this J~ay of~3, upon consideration of the within Petition and upon Motion of Reager & Adler, P.C., attorneys for the Petitioner, it is ORDERED that a citation be awarded and directly be served on Ralph C. Gundrum to show cause why a plenary guardian of his person and estate should not be appointed. At least twenty (20) days notice shall be given to him at his address of Manor Care Facility at 940 Walnut Bottom Road, Carlisle, Pennsylvania 17013. ~day of ,- 3, at )t~'clock, ~m, prevailing time at Returnable Orphans' Court room number .~ , Cumberland County Courthouse, One Courthouse Square, Carlisle, Pennsylvania, 17013, at which time a . Jo IN RE: RALPH C. GUNDRUM : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : NO.: 21-2003-0539 : : ORPHANS COURT DIVISION AFFIDAVIT OF SERVICE I, Linus E. Fenicle, hereby affirm that I served the Petition for the Appointment of Plenary Guardian together with the important Notice on the Citation on Ralph C. Gundrum at the Manor Care Facility, 940 Walnut Bottom Road, Carlisle, Pennsylvania at 6:00 p.m. on July 11, 2003. Date: ~//~//~'~ ~~/~ Linus E. Fenicle Sworn [0, and affnyned before me this t/t/~'day o[,d[~ , 2003. NOTARY PUBLIC / NOTARIAL SEAL ICASSANDRA T, ROSENBAUM, Notary Public ! Camp Hill Boro, Cumberland County IMy Commission Expires December 4, 2004 REAGER & ADLER, P.C. A'I-I'ORNEYS AT LAW 2331 MARKET STREET CAMP HILL, PA 17011-4642 IN RE: RALPH C. GUNDRUM IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION NO. 21-2003-0539 IMPORTANT NOTICE CITATION WITH NOTICE A petition has been filed with the Court to have you declared an Incapacitated Person. If the Court finds you to be an Incapacitated Person, your fights will be affected, including our fight to manage money and property and to make decisions. A copy of the petition which has been filed by Diane Haines is attached. You are hereby ordered to appear at a hearing to be held in Court Room No. 3, Cumberland County Courthouse, Carlisle, Pennsylvania, on August 12 ,2003, at 3:30 P.M. to tell the Court why is should not find you to be an incapacitated Person and appoint a Guardian to act on your behalf· To be an incapacitated Person means that you are not able to receive and effectively evaluate information and communicate decisions and that you are unable to manage your money and/or other property, or to make necessary decisions about where you will live, what medical care you will get, or how your money will be spent. At the hearing, you have the fight to appear, to be represented by an attorney, and to request a jury trial· If you do not have an attorney, you have the fight to request the Court to appoint an attorney to represent you and to have the attorney's fees paid for you if you cannot afford to pay them yourself. You also have the right to request that the Court order that an independent evaluation as to your alleged incapacity. If the Court decides that you are an Incapacitated person, the Court may appoint a Guardian for you, based on the nature of any condition or disability and your capacity to make and communicate decisions. The Guardian will be of your person and/or your money and other property and will have either limited of full powers to act for you. If the court finds you are totally incapacitated, your legal rights will be affected and you will not be able to make a contract or gift of your money to other property. If the court finds that you are partially incapacitated, your legal rights will also be limited as directed by the Court. If you do not appear at the hearing (either in person or by an attorney representing you) the court will still hold the heating in your absence and may appoint the Guardian requested. Clerk, orPhans C~"urt Divisior~ Cumberland County, Carlisle, PA ' My Commission Expires 1st Monday, Jan.uary, 2006 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 TABLE OF CONTENTS WITNESS FOR PETITIONER Darryl K. Guistwite, M.D. DIRECT GEIGER & LORIA REPORTING SERVICE - 1-800-222-4577 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 DARRYL K. GUISTWITE, M.D., called as a witness, being sworn, testified as follows: MR. FENICLE: I want to go on the record. I'm Linus Fenicle. I am here on behalf of the Petitioner for the appointment of a plenary guardian of the person in the estate of Ralph C. Gundrum. The purpose of this deposition is to elicit medical testimony in support of that petition for the guardianship appointment in regard to Ralph C. Gundrum. This testimony will be utilized in the Orphans Court proceeding that is ongoing at the present time. DIRECT EXAMINATION BY MR. FENICLE: Q Doctor, let's start with your name and your office address. A Darryl Guistwite at 522 South Pitt Street in Carlisle. Q And what type of practice do you have? A Family practice. Q Do you have any specialties? A Family practice and that involves hospital, nursing home and office practice. Q Are you licensed to practice in Pennsylvania? GEIGER & LORIA REPORTING SERVICE - 1-800-222-4577 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 A medicine? A Q A Yes. And how long have you been practicing Since July of 2002. What is your educational background? Medical school in Philadelphia at PCOM, Q Gundrum? A Q internship in Harrisburg at Pinnacle and family practice residency in York. Are you board certified in any specialties? Family practice. Have you either treated or examined Ralph Yes. And do you know the times or dates of your examinations or treatment and what were they? Would you explain that. A I've seen Ralph a couple months. was admitted to Manor Care on the west wing, which is where most new admit patients go. Karen Scott evaluated him for Arcadia, which is the primarily dementia or -- it's an exclusive dementia unit of Manor Care and it was found and I agreed that he belonged there. His main medical issues are dementia. Q And would you explain that in a little more detail. Initially he GEIGER & LORIA REPORTING SERVICE - 1-800-222-4577 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 A Sure. At Manor Care patients with medical issues, diabetes, blood pressure problems, status post stroke, belong on the west or the east wings, whereas Ralph doesn't have a lot of medical problems, but his dementia, probably Alzheimer's, is why he is in a facility and that area would be a dementia -- where he belongs is the dementia unit which is the Arcadia unit. Q The Arcadia unit, is it set off separately from other care of the Manor Care facility? A Correct. So he's free to move about and he's adjusted to being there in the last several weeks. I've seen him in the Arcadia unit I think three times in about -- close to a month he's been there, three to four weeks. Q And so the first time you saw him was a couple of months ago, is that correct, say maybe in April or May? A Um-hum. He was admitted and I think I'm the only physician to follow him there. Q And you indicated you've diagnosed him with dementia -- A Yes. Q -- is that correct? Have you done any studies or evaluations to confirm that diagnosis or -- A Um-hum. Could you explain that? I've spoken to him as well as he's been seen GEIGER & LORIA REPORTING SERVICE - 1-800-222-4577 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 by psychiatry as well and we both agree that he has dementia, probably of the Alzheimer's type, as well as he's had some testing done to somewhat confirm that. He scored 19 out of 28 on a mini-mental status exam which is a standard test for dementia. Q And does that score reflect dementia? A Yes, that reflects at least a mild to moderate decline in his overall cognitive ability, ability to reason and particularly short-term memory. Q What would be your prognosis for Mr. Gundrum in the future? A Prognosis with Alzheimer's is pretty variable, but I expect him to live there, barring other medical complications, several years. Q And would his mental condition or this dementia, Alzheimer's, would you expect to see that -- A Slowly decline on average. Usually a slow decline, unfortunately. Q Now, in regard to his physical limitations, he is in a wheelchair, is that correct? A Q wheelchair? A Q Correct. And is that the way he gets around, in a Yes. Does he have any limitations on -- or GEIGER & LORIA REPORTING SERVICE - 1-800-222-4577 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 impairments on his ability to speak? A Not that I can recall. of hearing. Q I know he's very hard Let me ask you some questions then about his ability to formulate decisions. Based on his condition would he be able to formulate reasonable decisions in regard to financial transactions, such as utilizing checking accounts and issuing checks? A No, that would not be in his best interest. And that's because of his mental state, is Q that correct? A Yeah, correct, short-term memory loss is not conducive to managing personal finances. Q How about reasonable decisions concerning physical and -- physical health and his safety? A No. Q Can he formulate or make reasonable decisions relative to giving consent for medical and surgical treatment? A No. Q Could Mr. Gundrum -- do you believe that he could prepare or purchase his meals? A No. Q How about can he prepare or perform personal care in an acceptable manner such as personal hygiene? GEIGER & LORIA REPORTING SERVICE - 1-800-222-4577 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Q impaired? A Q that correct? A Q A NO. Q Do you know if he does know his children, his children being Diane Haines and Luanne Gundrum? A I would say from the record that he does recognize others, staff, myself whenever I've gone to see him, yes. Q Is he oriented as to time and place as far as you know? A He was when I've seen him and psychiatry on 7/3 stated he was oriented times three which means to himself or -- as to himself, to time and to where he was. Q But he may have a problem with his short-term memory? A Oh, yes, his recall was zero out of three then. So given three objects, two minutes later he can't remember any of them. Is his ability to remember current events Yes. And that's because of what you just stated, is Um-hum. Could he be taken advantage of by unscrupulous or designing persons? A Absolutely. GEIGER & LORIA REPORTING SERVICE - 1-800-222-4577 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Q Now, if -- let me ask you this question: Would his presence at the court hearing in the courtroom be in his best interest as far as his physical or mental condition? A No. Q And could it even possibly be harmful to his mental condition? A Yes. Q Does he have the mental and physical ability to drive a vehicle with safety? A No. Q Could he fully understand the meaning and consequences of entering into a marriage contract if that ever came up? A No. Q And you've indicated he is in the Arcadia unit. What type of care do you receive in the Arcadia unit, if you could explain? A He receives the care that he requires for everything. He requires -- I mean, he's given food regularly. He's instructed to be involved in activities. He has free reign to move about the unit, which is fairly large, but he is with staff kept safe from other residents who also have free reign of the facility. And he's instructed and helped with -- depending on their level of GEIGER & LORIA REPORTING SERVICE - 1-800-222-4577 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 ability, helped with personal hygiene, bathing, etcetera. Is he capable of taking medication with Q safety? A He is given his medication there, but, no, he's not capable of keeping his own medications in his own room. In other words, he needs people to assist Q him - - A Q A Q Sure. -- in taking medication? Yes. Now, you've indicated that he has mild to -- or mild dementia -- I guess mild to severe dementia. How does this -- does this condition impair his ability to make decisions? A Definitely. Q And would that be the short-term memory loss and so forth that the dementia causes, is that correct? Is that what you mean when you say it impairs his ability to make decisions? A Yes. Q When he discusses things, are they understandable, are they related to the subject? A With Ralph -- he's at a stage in his Alzheimer,s that some days he may seem more coherent than GEIGER & LORIA REPORTING SERVICE - 1-800-222-4577 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 others, but in general his thought processes cannot be followed in a normal conversation. Some days may be better, some days may be worse. Q And this condition would affect his ability to communicate decisions and make decisions, correct? A Yes, definitely. Q In your opinion would he be able to conclude the purchase of an item in a retail store and understand it? A No. Q Could he pay his bills satisfactorily and keep a checking account and accurate records? A No. Q Now, as far as his physical limitations, he doesn't have the capacity -- or he is in a wheelchair at this time, is that correct? A Correct. Q And is it your opinion that it would be in his best interest to have a guardian of his person and his estate, is that your feeling on it? A Definitely, yes. Q You indicate there was a psychological evaluation done recently, is that correct? A Yes, this was in regards to him in his confusion making inappropriate sexual -- exhibiting inappropriate sexual behavior towards some of the staff, GEIGER & LORIA REPORTING SERVICE - 1-800-222-4577 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Q medication? A which is a common occurrence with dementia. That is a common occurrence? Yeah. Is he on any -- was he put on any type of He presently is on -- I don't have in front of me if he was on anything or not. I don't think psychiatry started him on anything at that point. Q So it would be your opinion that this condition that he has really totally impairs his capacity to receive and evaluate information effectively and make -- A Correct. Q And make and communicate decisions concerning the management of his financial affairs or even make arrangements for his physical health and safety, would you agree with that? A Correct. And any medication that would be started in the future would not -- that would -- would not correct that. Q A It would not correct it? It's not correctable. It is treatable. Treatable, but not correctable. Q In other words, Mr. Gundrum relies totally on the staff at the facility, the Manor Care facility, the Arcadia unit -- GEIGER & LORIA REPORTING SERVICE - 1-800-222-4577 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 A Yes. -- for his day-to-day activities? Yes. And in that he's been doing quite well with that care. Q And, again, you indicated that this condition impairs his condition, which is a lack of short-term memory and an inability to understand transactions of any complexity, is that correct? A Correct. Q And you would agree that he is an incapacitated person in that regard? A Definitely. MR. FENICLE: questions, Doctor. (The deposition was concluded at 1:25 p.m.) I don't believe I have any other GEIGER & LORIA REPORTING SERVICE - 1-800-222-4577 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 COUNTY OF DAUPHIN : : SS COMMONWEALTH OF PENNSYLVANIA : I, Teresa K. Bear, Reporter-Notary Public, authorized to administer oaths within and for the Commonwealth of Pennsylvania and take depositions in the trial of causes, do hereby certify that the foregoing is the testimony of DARRYL K. GUISTWITE, M.D. I further certify that before the taking of said deposition, the witness was duly sworn; that the questions and answers were taken down stenographically by the said Teresa K. Bear, a Reporter-Notary Public, approved and agreed to, and afterwards reduced to typewriting under the direction of the said Reporter. I further certify that the proceedings and evidence are contained fully and accurately to the best of my ability in the notes taken by me on the within deposition, and that this copy is a correct transcript of the same. In testimony whereof, I have hereunto subscribed my hand this 29th day of July, 2003. Teresa K. Bear, Reporter Notary Public My commission expires on April 25, 2007 GEIGER & LORIA REPORTING SERVICE - 1-800-222-4577 REAGER & ADLER, PC ATTORNEYS AND COUNSELORS AT LAW THEODORE A. ADLER + DAVID W. REAGER CHARLES E. ZALESKI LINUS E. FENICLE DEBRA DENISON CANTOR + Certified Civil Trial Specialist Writer's E-Mail Address: Ifenicle@epix.net 2331 MARKET STREET CAMP HILL, PENNSYLVANIA 17011-4642 717-763-1383 TELEFAX 717-730-7366 WEBSITE: ReagerAdlerPC.com June 27, 2003 THOMAS O. WILLIAMS SUSAN H. CONFAIR JOANNE H. CLOUGH SUSAN J. SMITH DOUGLAS P. LEHMAN Diane Haines 213 South Bellevue Avenue Langhorne, PA 19047 Re-' Dear Diane: Retainer Letter Our File No.: 03-274 It was a pleasure speaking to you recently regarding the guardianship matter. Thank you very much for your confidence in retaining us to represent you We look forward to working with you. The purpose of this letter is to set forth, in writing, the arrangements concerning our fee so that we may avoid any misunderstandings. Your bill will be based upon our hourly rates for all time devoted to your case at the hourly rates for the attorney performing the service and the periods during which services were performed based upon intervals of tenth(s) of an hour. We try to have the work done at the level which will be most efficient in terms of rates and costs to you. The time charged includes not only meeting with you and court appearances, but also drafting and reviewing pleadings and correspondence, telephone conversations with you, opposing counsel and other parties, time spent with witnesses, legal research, and travel. Please understand that all hourly rates charged to our clients may be increased from time to time by our firm, which is usually done each year or so. My rate for this case initially will be $165 per hour. We are requesting a retainer of $1,000, which is an advance deposit to be applied toward payment of your future bills. It is not, however, a minimum or maximum fee. Thus, if we conclude your case before the total hourly charges equal the amount of the retainer, you will receive a refund of the difference. On the other hand, if the total hourly charges exceed the amount of the retainer before our work is completed, you will be required to provide a new retainer. In addition to the charges for professional services, you will be responsible for timely reimbursing us for all of our own out-of-pocket disbursements, such as charges for long distance telephone calls, filing fees paid to the court, expert, appraisal, investigative and witness fees, travel expenses, messengers, transcripts of depositions, faxes and photocopies. 'Letter to Diane Haines Page 2 June 27, 2003 We will be sending you monthly statements as your case proceeds containing a description of how we have been spending our time on your behalf. We reserve the right to charge interest and/or to terminate our attorney-client relationship if you do not pay our fees and disbursements within thirty days of billing. You will be provided with copies of all pleadings, correspondence and other documents associated with your file which you should keep for your own records. After the conclusion of your case, our office will maintain a copy of your file in our closed file system for seven (7) years. After the seven (7) years, this file will be destroyed. You are consenting to this file maintenance system by signing this fee agreement letter. If this letter correctly conforms with your understanding of our arrangement concerning fees and costs, we would appreciate your signing the enclosed copy of this letter in the space indicated and returning it to me. Of course, should you have any questions or comments about this letter or the arrangements discussed above, please do not hesitate to give me a call. I look forward to working with you. Very truly yours, Linus E. Fenicle Reager & Adler, P.C. LEF/dmb i HAVE READ THE ABOVE RETAINER LETTER AND IT CORRECTLY SETS FORTH MY UNDERSTANDiNG iN REGARD TO MY FEE ARRANGEMENT AND REPRESENTATION BY REAGER & ADLER, P.C. Dated: Diane Haines REAGER & ADLER, P.C. BY: LINUS E. FENICLE, ESQUIRE Attorney I.D. No. 20944 2331 Market Street Camp Hill, PA 17011 (717) 763-1383 Attorney for Petitioner IN RE: RALPH C. GUNDRUM IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY NO.: 21-2003-0539 ORPHANS COURT DIVISION FINAL DECREE AND NOW, this /~'~ day of August, 2003, after a hearing in this matter and it appearing to the Court that Ralph C. Gundmm was served with a Citation and Notice of this hearing on July 11, 2003, and the Court finds that the physical or mental condition of Ralph C. Gundmm would be harmed by his presence at the hearing, it is ordered, adjudged and decreed that Ralph C. Gundmm be and is hereby adjudged a totally incapacitated person and Diane Haines is appointed permanent guardian of the person and permanent guardian of the estate C. Gundmm. J. By: Diane Haines Guardian for Ralph C. Gundrum 213 So. Bellevue Avenue Langhome, PA 19047 215-752-1065 IN RE: RALPH C. GUNDRUM IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY : : NO.: 21-2003-0539 : ORPHANS COURT DIVISION .. Financial Accounting from August 12~ 2003 to August 8~ 2004 Assets as of 8/12/2004: Certificate of Deposit - $ (Fulton Bank) Certificate of Deposit - (Fulton Bank) PNC Checking Account Balance - Total $ 17,100.00 35,309.67 18,470.73 70,880.40 Checkbook Activity: 8/12/03 8/15/03 8/15/03 8/21/03 Deposit (monthly payment from Ed Jackson) NeighborCare To: Reager & Adler (attorney fees for guardianship) Checkbook Balance: 18,470.73 + 232.20 18,702.93 324.63 18,378.83 1,081.62 17,296.68 + 1,035.00 18,331.68 9/01/03 Direct Deposit social security-August 9/01/03 9/1/03 Interest, PNC Deduct electronic fees April-August-$2./mo. + 1.84 10.00 18,333.52 18,323.52 9/3/03 9/04/03 9/10/03 9/15/03 9/16/03 9/19/03 9/22/03 9/22/03 9/22/03 9/25/03 9/25/03 9/26/03 9/26/03 To: PNC Bank for: safe deposit box rent Deposit CD interest Deposit Jackson payment To: HCR Manor Care September bill To: Reager & Adler legal fees To: NeighboreCare pharmacy bill To: HCR ManorCare skilled nursing charges 5/11/03 - 6/15/03 Direct Deposit - SS - September To: Reager & Adler retainer - estate litigation Capital Blue Cross quarterly payment West Shore EMS - BLS 9/2/03 transportation from Holy Spirit to ManorCare Deposit CD interest Interest, PNC 20.00 + 105.93 + 232.20 4,570.00 820.00 341.55 3,780.00 + 1,035.00 5,000.00 213.45 88.30 18,303.52 18,409.45 18,641.65 14,071.65 13,251.65 12,910.10 9,130.10 10,165.10 5,165.10 4,951.65 4,863.35 + 105.93 4,969.28 + 1.47 4,970.75 2 9/26/03 1 O/17/03 10/18/03 10/18/93 10/24/03 11/08/03 11/08/03 11/29/03 11/29/03 11/29/03 12/08/03 12/12/03 12/12/03 12/13/03 12/13/03 01/10/04 01/10/04 01/11/04 0l/11/04 electronic banking deduct Direct deposit SS - October Deposit - Jackson check NeighborCare Deposit - CD interest Direct Deposit Deposit - Jackson check Deposit - CD interest NeighborCare West Shore EMS - Carlisle - transportation and expenses to hospital Direct Deposit + SS - December NeighborCare Manor Care Deposit-Jackson check + Deposit - cash-in CD + $17,100. early penalty fee Direct Deposit + SS - January Deposit-Jackson check + + CD interest Interest PNC Oct. thru Dec. '03 Electronic fees 5.30 4,965.45 + 1,035.00 6,000.45 + 232.20 6,232.65 32.19 6,200.46 + 102.51 6,302.97 + 1,035.00 7,337.97 + 232.20 7,570.17 + 105.93 7,676.10 88.64 7,587.46 594.37 6,993.09 1,035.00 8,028.09 155.45 7,872.64 2,242.70 5,629.94 232.20 5,862.14 16,949.73 22,811.87 1,035.00 23,846.87 306.66 24,153.53 2.28 24,155.81 9.30 24, t46.51 3 01/11/04 01/11/04 01/11/04 02/02/04 02/07/04 02/07/04 02/19/04 02/19/04 02/20/04 02/01/04 03/04/04 03/11/04 03/16/04 03/18/04 03/22/04 03/24/04 03/30/04 04/05/04 Cumberland Valley Medical Services- For Dr. consult NeighborCare ManorCare Direct Deposit + SS February Deposit + CD interest West Shore EMS-BLS 1/3/04 call NeighborCare ManorCare for Feb. + misc. expenses Deposit-Jackson deposit + West Shore EMS-Carlisle - Direct Deposit + ManorCare for March + Dec.& Jan. adjustments + misc.exp. NeighborCare Deposit - CD interest + Carlisle Regional Med. Kenneth Guistwite M.D. Capital Blue Cross - 1/01/04 thru 6/30/04 Direct Deposit + SS April 8.47 86.55 8,295.00 1,035.00 7T15 32.00 319.30 5,525.75 232.20 69.53 1,035.00 7,472.75 201.99 319.82 58.40 160.48 426.90 1,035.00 24,138.04 24,051.49 15,756.49 16,791.49 16,868.64 16,836.64 16,517.34 10,991.59 11,223.79 11,154.26 12,189.26 4,716.51 4,514.52 4,834.34 4,775.94 4,615.46 4,188.56 5,223.56 4 04/07/04 04/12/04 Deposit-cash-in final CD * $35,309.67 less early penalty fee -$34,894.53 + $72.41 CD interest ManorCare April bill 34,966.94 5,813.25 40,190.50 34,377.25 05/05/04 05/05/04 05 / 10/04 05/10/04 05/25/04 05/26/04 06/07/04 06/08/04 06/08/04 06/17/04 06/24/04 07/03/04 07/08/04 Deposit - Jackson check Direct Deposit SS May ManorCare May bill/Apr.misc.exp NeighborCare Paul J. Creedon,DPM foot care Deposit litigation settlement $5,000 + Jackson check Capital Blue Cross 7/1/04 - 9/30/04 Deposit - Jackson check + magazine refund Direct Deposit SS- June ManorCare Carlisle June bill/Apr.misc.exp. NeighborCare Direct Deposit SS July ManorCare Carlisle July bill/June misc.exp. + 232.20 34,609.45 + 1,035.00 35,644.45 5,794.50 29,849.95 744.02 29,105.93 20.00 29,085.93 + 5,232.20 34,318.13 213.45 240.67 1,035.00 5,814.31 805.76 1,035.00 5,803.00 34,104.68 34,345.35 35,380.35 29,566.04 28,760.28 29,795.28 23,992.28 5 07/30/04 08/04/04 08/05/04 08/06/04 08/06/04 Deposit Jackson check + + $2,034.44 retainer refund from Reager & Adler NeighborCare Direct Deposit SS - August Interest - PNC Jan. thru July Electronic deductions PNC Jan. thm July 2,266.64 178.01 1,035.00 13.62 20.60 26,258.92 26,080.91 27,115.91 27,129.53 27~108.93 6 By: Diane Haines Guardian for Ralph C. Gundrum 533 W. Maple Avenue Langhorne, PA 19047 215-752-1065 S~ o . ,:,~ (, .r'-~ . r -~., -'TJ ;:.;< ::"-,1 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY IN RE: RALPH C. GUNDRUM NO.: 21-2003-0539 ORPHANS COURT DIVISION : Financial Accountin2 from AU2ust 8. 2004 to AU2ust 12.2005 Checkbook Activity: 8/8/04 Checkbook Balance: 27,108.93 8/9/04 Deposit + 232.20 (monthly payment from Ed Jackson) 27,341.13 8/9/04 To: HCR ManorCare August bill 21,527.88 - 5,81325 8/9/04 To: Dr. Guistwite (attorney fees for 21,518.32 9.56 8/16/04 To: Cumberland County - 10.00 21,508.32 Orphan's Court - filing Fee, Guardian report PNC Bank 20.00 21,488.32 Safety Deposit Fee To: NeighborCare 405.42 21,082.90 9/9/04 9/9/04 9/9/04 Direct Deposit 22,117.90 + 1,035.00 - gl1 '" = C.:::J' 1.:-" CD en Co C' ::TJ '.J f"'l '::J C) ; -Tl -. (~:5 rTl ,).~ (/) r--:j -" 1 CO -0 t',) --.: SS - September 9/14/04 To: HCR ManorCare - 5,813.25 16,304.65 September bill 9/14/04 To: Capital Blue Cross 213.45 16,091.20 quarterly payment 9/16/04 Deposit + 232.20 16,323.40 (montWy payment from Ed Jackson) 9/30/04 Deposit + 2,500.00 18,823.40 final van payment 10/3/04 Direct Deposit + 1,035.00 19,858.40 1017104 Deposit + 232.20 20,090.60 Ed Jackson payment 1017104 To: NeighborCare 222.98 19,867.62 pharmacy bill 1017104 To: HCR ManorCare - 5,803.00 14,064.62 SS - September 10113/04 To: NeighborCare 176.89 13,887.73 pharmacy bill 1111104 Adjustments - SS + 150.00 14,037.73 increase-Jan. - Oct. 1111104 Checking Acct. Interest + 3.72 14,041.45 11/1104 Checking Account 7.30 14,034.15 Electronic ded~ctions 1111104 To: DilIsburg Banner 16.50 14,017.65 local paper subscription 1112/04 Deposit + 232.20 ]4,249.85 Ed Jackson payment 1113/04 Direct deposit + 1,050.00 15,299.85 S5 - November 2 11115/04 To: HeR ManoFCare 5,813.25 9,486.60 11119/04 To: NeighborCare 181.89 9,304.71 1215/04 Direct Deposit + 1.050.00 10,354.71 SS - December 12/5/04 Checking Acct. Interest + 1.06 10,355.77 12/5104 Checking Account 2.00 10,353.77 Electronic deductions 12114/04 Deposit + 232.20 10,585.97 Ed Jackson payment 12/15104 To: Dr. Creedon 20.00 10,565.97 foot care 12/15/04 To: Capital Blue Cross 213.45 10,352.52 12/15/04 To: NeighborCare 126.32 10,226.20 pharmacy bill 12/15104 Clothing & necded items - 195.83 10,030.37 12115/04 To: ManorCare 2,034.37 7,996.00 Pending county assistance 12/31/04 Statement copy charges 69.43 7,926.57 (-65. -5.30 + 1.87 interest) 1/12/05 To: HCR ManorCare 1,020.00 6,906.57 III 5/05 Direct Deposit + 1,068.00 7,974.57 SS - January .. 1115/04 Deposit + 232.30 8,206.77 Ed Jackson payment 1/1 5/05 adjustment 1.33 8,205.44 (interest - deductions) 2/7/05 To: Neighborcare 106.62 8,098.82 pharmacy bill 2/7/05 To: ManorCare 1,056.00 7,042.82 , ~ February payment 2/7/05 Direct Deposit + 1,068.00 8, 1l0.82 SS - February 2/7/05 Deposit + 232.20 8,343.Q2 Ed Jackson payment 2/8/05 To: HCR ManorCare 464 .40 7,878.62 Jan.&Feb. Jackson payments 3/15/05 To: HCR ManorCare 1,046.75 6,831.87 March payment 3/15/05 Direct Deposit + 1,068.00 7,899.87 S5 . March 3/15/05 Deposit + 232.20 8,132.07 Ed Jackson payment 3/15/05 To: Capital Blue Cross 21345 7,91862 quarterly payment 3/24/05 To: Cumberland Valley 8.73 7,90989 Medical Services 4/12/05 To: HCR ManorCare 1,260.20 6,649.69 April payment 4/12/05 Direct Deposit + 1,068.00 7,717.69 55 - April 4/12/05 Deposit + 232.30 7,949.89 Ed Jackson payment '. 4/15/05 To: Paul J, Creeden DPM 20.00 7,929,89 foot care 5/11/05 To: HCR ManorCare 1,260.00 6,669.69 May payment 5/12/05 Direct Deposit + 1,068.00 7,737.69 55 - May 5/30/05 Deposit + 232.20 7,969.89 4 6/12105 To: Alan Haines 145.00 7,82489 turnpike expenses (5x-2004, 5x-2005/S14.50) 6/12105 To: Capital Blue Cross 265.29 7,559.60 quanerly payment 6/12105 To: HCR ManorCare 994.91 6,564.69 June payment 6/13/05 Direct Deposit + 1,068.00 7,632.69 SS - June 6/30/05 Deposit + 232.20 7,864.89 Ed Jackson payment 7/7/05 To: Dillsburg Banner 16.50 7,848.39 local paper subscription 7/8/05 To: HCR ManorCare 1,260.20 6,588.19 July payment 7/8/05 Direct Deposit + 1,06800 7,656.19 SS - July 7/9/05 Deposit + 232.20 7,88839 Ed Jackson payment 8/10/05 To: HCR ManorCare 1,260.20 6,62819 August payment 8/12105 Direct Deposit + 1,068.00 7,696.19 SS - August 8/12105 Triangle Clothi.ng Store 100.00 7,596.19 clothing & items 8/12/05 Checking acct. interest + 4.11 7,600.30 Feb.-July 8/12105 Checking acct. deductions 26.60 7.573.70 Feb. - July 5 By: Diane Haines Guardian for Ralph C. Gundrum 533 W. Maple Avenue Langhorne, P A 19047 215-752-1065 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY IN RE: RALPH C. GUNDRUM NO.: 21-2003-0539 ORPHANS COURT DIVISION Financial Accounting from August 13. 2005 to August 12, 2006 Checkbook Activity: 8/12/05 8/30/05 8/30/04 9/5/05 9/5/05 9/5/05 9/15/05 9/15/05 Deposit: (Ed Jackson payment plus refund from Cumberland Rescue) + 240.93 To: Cumberland County - 10.00 Orphan's Court filing fee To: Cumberland County - 5.00 (additional filing cost) To: PNC Bank 25.00 Safety Deposit Fee To: HBCS 840.00 for Holy Spirit bill 9/2/03 To: Capital Blue Cross 265.29 lOll /05 to ] 2/31/05 To: ManorCare 994.91 September Checkbook Balance: 7,573.70 7,814.63 7.804.63 7.799.63 7,774.63 6,934.63 6,669.34 5.674.43 9/15/05 Direct Deposit - Sept. + 1,068.00 6.742.43\ Social Security 10/1 /05 Deposit: Ed Jackson + 232.20 6.974.63 September 10/2/05 To: ManorCare 1.260.20 5.714.43 Octo ber 10/12/05 Direct Deposit + 1,068.00 6,782.43 October SS 11/1/05 Deposit: Ed Jackson + 232.20 7.014.63 October 11/1/05 Deposit: Ed Jackson + 232.20 7.246.83 November 11/14/05 To: ManorCare 1,260.20 5,986.63 November 11/15/05 Direct Deposit + 1.068.00 7,054.63 November SS 12/9/05 To: Capital Blue Cross - 265.29 6.789.34 1/1/06 to 3/31/06 12/9/05 To: ManorCare 994.91 5,794.43 December 12/1 0/05 Direct Deposit + 1.068.00 6,862.43 December SS 1/13/06 Deposit: Ed Jackson + 464.40 7.326.83 December & January 1/13/06 To: ManorCare 1,297.20 6.029.63 January 1/14/06 Direct Deposit + 1,1 05.00 7.134.63 January SS 2/9/06 To: ManorCare 1,297.20 5.837.43 February 2/24/06 Direct Deposit + L 1 05.00 6.942.43 2 February SS 3/12/06 To: Manor Care 1,065.00 5,877.43 March 3/14/06 Direct Deposit + 1,105.00 6,982.43 March S S 3/14/06 To: Capital Blue Cross 265.29 6,717.14 4/1/06 to 6/30/06 3/16/06 Deposit: Ed Jackson + 232.20 6,949.34 Feb. - Final Payment 4/12/06 To: Manor Care 799.71 6,149.63 April 4/14/06 Direct Deposit-April + L 105.00 7254.63 5/7 /06 To: Manor Care 1,065.00 6,189.63 May 5/7 /06 To: Alan Haines 195.00 5,994.63 Clothing for Ralph, tolls 5/8/06 Direct Deposit-May + 1.105.00 7.099.63 6/9/06 To: Manor Care-June 1.065.00 6,034.63 6/9/06 To: Diane Haines 11. 98 6,022.65 Clothing for Ralph 6/9/06 Direct Deposit - June + 1,105.00 7,127.65 6/21/06 To: Capital Blue Cross 265.29 6,862.36 7/1/06 to 9/30/06 7/13/06 To: Manor Care-July 799.71 6,062.65 7/15/06 Direct Deposit-July + 1.105.00 7,167.65 8/7 /06 To: Manor Care 1.065.00 6,102.65 August 8/12/06 Checking acct. interest + 7.48 6,110.13 August 05-July 06 '") .:l 8/12/06 Checking acct. deductions 8/05-7/06 HCR resident trust fund as of 6/30/06 + 61.20 469.65 4 6,048.93 6,518.58 Total , Estate o~ (~ \? '" also known as PETITION FOR PR~~ AND GRANT OF LETTERS REGISTER OF WILLS O~". ~"""'\ c\ COUNTY, PENNSYLVANIA Q r G\')~~~\)l~ File Number 6)()(j3- os~9 . Deceased Social Security Number d.. ~ \ ,\ ~ - ~ ( ~ Petitioner(s), who isl~ years of age or older, apply(ies) for: (COMPLETE ~' or 'B' BELOW:) ~ A. Probate and Grant of Le rs T tamentary and aver that Petitioner(s) is / are the last WiI1 of the Decedent dated 0 and codicil(s) dated \'\.'-lLS named in the (State relevant circumstances. e.g., renunciation. death of execUlor, etc.) Except as follows, Decedent did not marry, was not divorced, and did not have a child born or.adopted after execution of for probate, was not the victim ofa killing and was never adjudicated an incapacitated person: \ 'f\~~ . o B. Grant of Letters of Administration (Ifapplicable, enter: c.t.a.; d.b.n.c.t.a.; pendente lite; durante absentia; durante minoritate) Petitioner(s) after a proper search has / have ascertained that Decedent left no Will and was survived by the following spouse (if any) ~.heirs: (If Administration, c.t.a. or db.n.c.t.a., enter date o/WiIl in Section A above and complete list o/heirs.) C) :.:; ~~ ~ ...:,.... ,- C_}, :: ,I ~ Name Relationship .-~ P....) .... Decedent, then <c \ years of age, died on 6<,00) Decedent at death owned property with estimated values as follows: (If domiciled in P A) All personal property (If not domiciled in PA) Personal property in Pennsylvania (lfnot domiciled in PA) Personal property in County Value of real estate in Pennsylvania situated as follows: \~~ "'\ s ~C)c}O S S S _ Wherefore, Petitioner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented with this Petition and the grant of Letters in the appropriate form to the undersigned: T or rinted name and residence Form RW-02 rev. /0.13.06 Page 1 of2 Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA COUNTY OF b~, \o.-ncA : SS The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true and correct to the best of the knowledge and beliefofPetitioner(s) and that, as personal representative(s) of the Decedent, Petitioner(s) will well and truly administer the estate according to law. Sworn to or affirmed and subscribed _..........O~~ before me tfi?<, (~~ ~ ..p,,,,,,,,,, R...,.; . , - - - ~ 'L:. Signature of Personal Representative Signature of Personal Representative Estate of ~O--~Y\ d-a \ \ CO olLtci . d bD -1 d \ CJ ~ 6S~ ~ ~. (;LL\\d..~ , Deceased File Number: Social Security Number: Date of Death: bL\- ()\ -- (J I AND NOW, mQ.....L.\, ~ having been presented before me, IT IS DECREE1\> that Letters are hereby granted to ,~c:v--Q . ~Q.,' ~~ S . in consideration of the foregoing Petition, satisfactory proof \f,~~~ , in the above estate and that the instrument(s}dated ~ ~'\ \ \ \ ~ J 0 ()d., described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent. _ J1~ ~J\QJ-- ~\U~'-~. Register of Wills . (r' ~ FEES Letters ............... $ Short Certificate(s) . . (? J.. $ Renunciation(s) .......... $ W\\\ ... $ ...jL~ ...$ \\ "'- \-U ... $ ... $ .. . $ ... $ ... $ ... $ .. . $ TOTAL.. .. .. .. . .. ... $ 3~ ' t)C) d D . C)t) Attorney Signature: \S.C>D \D DO SoD Attorney Name: Supreme Court I.D. No.: Address: Telephone: '80 DC :0!18 Form RW-02 rev. 10./3.06 Page 2 of2 H 105.805 REV 1105 This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. No. 40;- a OLU~1". . Local Registrar Fee for this certificate, $6.00 p 13509792 4. 3, 07 Date .,,- ..., :',::~-~ 't.. --~. --' .-.~.. .. ~. ~ ~ -"- I N P3 !Jl :> ~ ;i COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH (See Instructions and examples on reverse) ~~ H1~143 REV 11f.!006 TYPE I PRINT " PE_HT SlACK INK Twp. Cilylllonl , , ~ ... .+ " ...~ N '" j 308. Was an AwJpsy I'olloImed? d. 301>. .... ,"""",y Fir1din9S AYailablePliorlo~ of Cause 01 Death? DYes ~ 31.Mame<0I1Jealh ~"'al D- 0-' 0 Pendongl~ o SuicMle 0 Coold Not lie Oelelmlned Appfo.w.inate llIeNaI: Part u: EnIeIolher sqiicanI CUldiIion!l; lXInkIluIino kJd&aIh, 28. Did TOOaa:oUse CoIiri:Ue 10 0eaIh? ar..t 10 0eaIh but no/ IeslllIng ~ lI1t ~ causo gMln ~ PM'. 0 Yeo 0 """""Y OHo 0"""""'" 29.IIF....: o NotpllglVllll_pastyoar o P_III linlo 01_ o Not_butpllglVllll_""'" 01_ o NoIplIgIVIlII,but",_43""'IO'yoar ..... - o """""""plIgIVIlII_..."",yoar :l2c'==:'i~j9r""F"""', ~~=,~ _1st_,,0Ry, ~ 10 lie cause Iisied on Wle a. Enter lie UNOERlY1HG CAUSE (dseaseor~l\atililialed1he evenlsfediAg lRdeath)LAST. Due to (Of as a consequence 01): Due 10 (or as a COl'lSeQLlence of) J "J "r-. \) "J ~ "- \ ! hl Q o ~ Dyes ~ 32d. Tlffi&oflnjury .. 331. Ctttdier Idled< ""'OlIO' c.tlIyIng phytlciIll 1_ _ cause 01 _.... _ phy"""'has """"""'" _ and """'"'"" Item 231 To" bII1 of my knowIIdgI. dNIh oc.cwred due Wi the ClUlt(t)and IDIMiIf II JtaIecL........................... _..... _... _.. _.. _.. _.. _.. _.. _.. ~==:t:::=~~':::':'::"~'":"'::'''1.IO==_..___________________ 0 :::::==-..=ondlllflnvnliglllion.ln"'Y..........__edlll..._._.ondplace.ond....lOlI1t_.lond_..slIted.. 0 I ~I c).J ~I ~ I 4 I ~/?~/ Disposition Permit No. ()13~qSo REAGER & ADLER, P.C. BY:L~SE.FENlCLE,ESQUIRE Attorney I.D. No. 20944 2331 Market Street Camp Hill, PA 17011 (717) 763-1383 '03 AGO 12 P 3 :42 Cl'ln~""'" , t l.h".; ,:~,) r......J ~g ....... Attorney for Petitioner , "":.; N IN THE COURT OF COMMq~~LE~ CUMBERLAND COUNTY :;~2;": ::1: g :"T-' :=~: f~ :"::;.JJ -<:: IN RE: RALPH C. GUNDRUM ~~\ N ., .x::- . NO.: 21-2003-0539 ORPHANS COURT DIVISION FINAl, DECREE 11+ AND NOW, this 11... day of August, 2003, after a hearing in this matter and it appearing to the Court that Ralph C. Gundrum was served with a Citation and Notice of this hearing on July 11,2003, and the Court finds that the physical or mental condition of Ralph C. Gundrum would be harmed by his presence at the hearing, it is ordered, adjudged and decreed that Ralph C. Gundrum be and is hereby adjudged a totally incapacitated person and Diane Haines is appointed permanent guardian of the person and permanent guardian of the estate of Ralph C. Gundrum. Isl ~9l f. ~ Diane Haines 533 W. Maple Avenue Langhorne, PA 19047 215-752-3338-hoDle 267-980-3534 - cell S3~ (j'6- D April 29, 2007 ,"-. .._~ ~ ..--\ 'C-l;T-". Cumberland County Court of Common Pleas A TTN: Register of Wills Cumberland County Courthouse 1 Courthouse Square Carlisle, PA 17013-3387 \ r~' .-----\ ,'- .~.- Re: Estate of RALPH C. GUNDRUM Dear Sir or Madam: My father in the above referenced matter named me as his executrix. I live in Bucks County, PA. I initially appeared at our Bucks County Register of Wills with the original Will and a death certificate. Enclosed are the forms to begin the probate and administration process and a check for $80.00, the amount quoted to me via my telephone conversation with your office, which includes the cost of five short certificates. Please contact me with any questions. Sincerely, G~~ Diane Haines Enclosures BarbaraG. Reilly Register of Wills of Bucks County, Pennsylvania List of Beneficiaries Estate of ~R ALP J-I C I G'LA N bR U WI File No. Beneficiary Address /V1 A RY ("TO L 'tJ .A ffl- G- Q 4__15 SUN-Sf'l LANE, APT: #/ YOR-K 'PA J? 'If) ~ /16NR. Q. U I\l D RJ.l fV1 jD05 BAyS/ATE AVf.. A-p" Blob 'Pt/~ALo Co <?/IJOS- / , ;).3:25 fkMV f( '-I tV TO fA) AJ Fi R l.. Com P AfIJ Y FRAN ~ LI rJ TO will _ '15A /fJ3J..3 ])IL.LSA uR.G- L IDN!:. CL.UA f ])JLLS(3 UR-~ ''"PA I '70/0 LU/t-rJf.- Gu.Al Da.LlYVI I g 37 tV OR.TH ])E F IANeL ST. fA COMA WA OJ gL}ob- ;)5 It../- D IAN f.- tJ A-IAJ€5 533 W, iY'fA-PU Avr, LA IV GHo IW l 'PA /'101/-1 I =:.;; () .:'~~- ~ ::; .:;:.z: - ! '. co: '... ......., j ) ). -'..;.;' . -.,.... ".' ::-:: ....1 .. -:~ ~- .,t- - RW 17 (11/99) ~ f lJ1RrJ lr antl ol RALPH C. GUNDRUM '"" .--..~ -. ~ i, Ralph C. Gundrum, of 10 East South Street, Box 42, FranknntQwn~"~'ork County, Pennsylvania, being of sound and disposing mind, memory anduQderst~nding, ~ , .. do make, publish and declare this to be my Last Will and Testament, hereby r~voking and making void all previous Wills and Codicils heretofore made by me. FI RST I order and direct my personal representative hereinafter named to pay all of my just debts, funeral expenses and expenses involved or connected with the administration of my estate as soon after my death as is reasonably possible. However, my personal representative need not accelerate and pay those unmatured obligations which, in his, her or its opinion, it might be proper and more advantageous to retain or renew and pay as they become due and payable. It is my desire to donate any and all organs and/or body parts to Humanity Gifts and/or any other organization of similar service as long as my estate incurs no charge for these donations. The rest of my remains shall be cremated. I authorize my personal representative in his, her or its sole discretion, to dispose of my ashes as they deem fit, and to expend sums from my estate for this purpose. SECOND I give, devise and bequeath the sum of five thousand ($5,000.00) dollars to my sister, MARY GOLDBERG of 2201 Carlisle Road, York, Pennsylvania providing that she survive me by sixty (60) days. ;2e G- I~ I give, devise and bequeath the sum of five thousand ($5,000.00) dollars to my brother, HENRY B. GUNDRUM of Avondale, Colorado, providing that he survive me by sixty (60) days. I give, devise and bequeath the sum of five thousand ($5,000.00) dollars to the FRANKLlNTOWN FIRE COMPANY. I give, devise and bequeath the sum of one thousand ($1,000.00) dollars to the DILLSBURG LIONS CLUB. I give, devise and bequeath the rest, residue and remainder of my entire estate together with all insurance proceeds thereon of whatever nature and wheresoever situate in equal shares to my daughters DIANE M. HAINES and LUANE D. GUNDRUM, who survive me by sixty (60) days, per stirpes. FOURTH My executor and trustee are authorized and empowered to exercise from time to time in his, her or its sole discretion and without prior authority from any Court, in respect of any property forming part of any trust hereby created or otherwise in its possession hereunder all powers conferred by law upon trustees or executors and the testator intends that such powers be construed in the broadest possible manner. FIFTH I nominate, constitute and appoint my daughter, DIANE M. HAINES, Executrix of this my Last Will and Testament. In the event DIANE M. HAINES is deceased, unable or unwilling to serve or shall cease to serve for any reason whatsoever, then I nominate, constitute and appoint LUANE D. GUNDRUM, to serve instead. I direct that my personal representative shall not be required to give or post bond for the faithful performance of his, her or its duties in this or any other jurisdiction. {2c G- SIXTH I hereby declare it to be my expressed desire that my personal representative employ Greason Law Offices of Cumberland County, Pennsylvania, for legal advise and assistance regarding this my Last Will and Testament, they having considerable knowledge of my affairs, including additional documents, and my views and wishes respecting any matters that may arise at the probate of this instrument, the administration of my estate, and the execution of the powers herein mentioned. IN WITNESS WHEREOF, I have hereunto set my hand to this my Last Will and ~ Testament this _10 day of Avr 1\ ,2002. / //l>>~ .4d1bJr-- Witness ""1 J(~t~D~~/~~;>q~':~y;, ~l~~> 'tn s ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA :SS COUNTY OF I, Ralph C. Gundrum, the Testator whose name is signed to the attached or foregoing instrument, having been duly qualified according to the 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. '1' ;dL /~ (~/ / / ,'t) 'r. v ~~~ //,,- (' RALPH C. GUNDRUM Sworn or affirmed and acknowledged before me by Ralph C. Gundrum, the Testator, this \ 0 day of Apr- ~ \ ,2002. . Notarial Seal I Usa M. Greason No!mY Pa4JIIc Carlisle Boro, Cumberlarid ._~?<>mmlssion E!ir'9S sept~ AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA : SS COUNTY OF We, t-u.r~ M.. Aclcu"A~ and ~l'Y\i~ L 4~ ,the witnesses whose names are attached to the foregoing document, being duly qualified according to the law, do depose and say that we were present and saw Testator sign and execute the instrument as his Last Will and Testament; that he signed willingly and that he executed it as his free and voluntary act for the purposes therein expressed; that each subscribing witness in the hearing and sight of the Testator signed the Last Will and Testament as witnesses and that to the best of our knowledge the Testator was at the time 18 or more years of age, of sound mind and under no constraint or undue influence. ~~1fc-: ~~~ Sworn or affirmed and subscribed before me by -tt,,y tbC\ 0;\. A c:llL'Yl\.O and "j~sL. fl~ this )0 day of __~_f}r'l \ ,2002. /~r~ e-/Notary P~lic Notarial Seal Usa M. Greason. ~ Public Carlisle Boro, Cumberl8rid Oculty My Commission Expires Sept. 9. 200~ Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 HAINES DIANE 533 WEST MAPLE AVENUE (") So "-j~ ~-o ~~.i~ -............ ;'--j~.. /.;.~ ......:> g -..I > c: G'") I Date: 07/31/2007 LANGHORNE, PA 19047 ;a~i~ '::0 --j :0- =ii: 00 W (]"\ .:-) RE: Estate of GUNDRUM RALPH C File Number: 2003-00539 Dear Sir/Madam: This notice is to serve as a reminder that the Certificate of Notice under Rule 5.6(a) is due on the below listed date. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after July I, 1992, the personal representative or his councel, within ten (10) days after giving proper notice to the beneficiaries and intestate heirs as required by subdivision (a) of Rule 5.7, shall file with the Register of Wills or Clerk of the Orphans' Court his/her Certification of Notice. This filing lS due by: 08/12/2007 Please feel free to contact this office with any questions you may have. If you have already filed your certificate, please disregard this notice. Sincerely, /a4Vkd l;t;Jt.<_/,~Aa;~~ 'Glenda Farner Strasbaugh Clerk of the Orphans' Court cc: File Counsel ~ CERTIFICATION OF NOTICE UNDER Pac O.C. Rule 5.6(a) 1 REGISTER OF WILLS efA rn,fJJtt2..LAJJ () COD'NTY, PENNSYLVANIA Name of Decedent: '!<A '-- fJ!-I C, C u..1II D I<.u. fV( Date ofDeau~: 1(; I () 7 . ' File Number: d.1 -0.3 - 053 C; Date Letters Granted: .5 / Lf / 0 rt I , -I- To the Register: I certify that Notice of Estate Administration required by Pa. O.C. Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on 0/L/- . d007 : , Name: Address: Ll..{A1J~ Q.utJbfhU'Yf /g31 N, ])EFIAf\JC€... ST.: 1I1(:0t1'1I1, WA orf?L./Db-J5/Y- (Y\AP-Y b-OLDIYtlLG- J'-f35 SU!l~ET Lllf'Jf, !/PT.#1. j6fU!., fA 1'7'fo? HGl4!_'y ~U.N f)f<.u.rII 2oo5:BAj ~TI11€ /lVt. APr: 3h';PutfJ LOj CO r;{/OOE- ])/LL5f3UJUr L{o/V~ CLU.!3 fo Box O//,'( DILL5BUR6} fA /?o/9 a3;}S E~NroWN eDfY\~t.l.rJiTY Ftr<.i: 0:>. ' l3A L If(Y\ {)/ll, S7I!-lLT, FtZAtvK.Lrl./TOw/I(PA 173;;. 4 (Ifmore space is needed, attach separate sheet.) Notice has now been given to all persons entitled thereto under Pa. O.C. Rule 5.6(a) except: co M .. Dale <gl'f/Ol ~t I c... Lt.. C', C-;,('''.. Capacity: 9Q' Personal Representative ]) I ANt. ~I If ( tJ t5' Name of Person Filing this Form 5.3..3 \J. rAil PLLA Vt.. Address LA,. b l-l bR..foJ l-.fA 1-1 . J t5 - ? 5 d - :3 3 3fj o Counsel ( ro I (.!J ~- oa::.c ! , u1 ::_~-: U~-E u.: 0::.." c5 ) 904-1 C.d) - J b 1- 980 - 352'1 ,...... c-:-. '" Telephone Form RW-08 rev, iO.H06 ~ OJ (V) THE PATRIOT NEWS THE SUNDAY PATRIOT NEWS 0: Proof of Publication Cnder Act No. 587. Approved May 16.1929 Commonwealth of Pennsylvania. County of Dauphin: ss co >< ,',. I '-L 0".. g ~Et "Q:: & ~, := Josep:hJ x.;: Dennison. being duly sworn according to la\v. deposes and says: i:'J That he k'the .-\ssistant Controller of The Patriot NeViS Co.. a corporation organized and existing under the la \\S of the Conm10n\\ealth of Pennsyhania. with its principal oUice and place of business at 812 to 818 \Jarket Street. in the City of Harrisburg. County of Dauphin. State ofPennsylnnia. owner and publisher of The Patriot- :\ews and The Sunday Patriot-Ne\vs newspapers of general circulation. printed and published at 812 to 818 Market Street. in the City. County and State aforesaid~ that The Patriot-Ne\vs and The Sunday Patriot-News were established rvlarch 4th. 1854. and September 18th. 1949. respectively. and all have been continuously published e\er ~Il1ce : That the printed notice or publication which is securely attached hereto is exactly as printed and published in their regular daily and or Sunday \iletro editions \vhich appeared in the 3rd. 10th and 17th day(s) of July 2007. That neither he nor said Company is interested in the subject matter of said printed notice or advertising:. and rha[ all of the allegations of this statement as to the time. place and character of publication are true: and That he has personal kno\\ledge of the facts aforesaid and is duly authorized and empowered to writ'y tIns 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 ":\1", Volume 14. Page 317. PUBLICA TION COpy Sworn to and sub \.. . Meeting Notices Estate Notice Letters Testamentary on the Estate of Ralph C. Gundrum, late of South Middle. ton Twp., Cumberland County, PA have been granted to the undersigned. All persons Indebted ta saId Estate are re- quired to make Immediate payment and those having claIms will present them tor settlement to: DIane Haines, Execu- trix, 533 W. Maple Ave., Langhorne, PA 19047. DIANE HAINES 533 W. MAPLE A VENTE LANGHORNE. PA. 19047 Cb 15056051058 REV- ^ 5OO EX (06-OS) OFFICIAL USE ONLY PA Department of Revenue Count Code Year File Number Bureau of Individual Taxes y PO BOX 280601 INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT ~I ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth Decedent's Last Name Suffix Decedent's First Name MI Gu~n2uM _ _ R ~~P~ c (If Applicable) Enter Surviving Spouse's Information Below Spo/use's Last Name Suffix Spouse's First Name MI /-'/~ _ __ Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 1. Original Return _ 2. Supplemental Retum _~. 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate 4a. Future Interest Compromise (date of +.;. ~~~ 5. Federal Estate Tax Return Required death after 12-12-82) ~i- 6. Decedent Died Testate 7. Decedent Maintained a Living Trust _ _~ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust} 9. Litigation Proceeds Received 10. Spousal Poverty Credit (date of death .:.... 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number __ Firm Name (If Applicable) -__.r . <7 REGISTER Of VVECLS USE ~. , -7 ,~ ` First line of address ~ ~~i ICi'1 ~ ~. ~~3 w, r~r4P~~.~u~r ~--~:, , _ t__ _ ~ ~~ , ~ _,-~ Second line of address ~ ~~ _„_ _:, - ........ N ~ `: v ~ c 1 -ice ~ t° City or Post Office _ _ State......... ZIP Code DATE FILED CEO Correspondent's a-mail address: d I Q ~ ~h ~o~ ~ ~ ~' ~ l1'f C'fF BT~ ~ ~ ~ Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. ;E OF PERSON f~ESPONSIBLE FOR FILING RETURN ~ (~ / b ADDRESS ~ t r ~ f ~ ( , SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 15056051058 l~/ J 15056052059 REV-1500 EX Decedent's SocialpSecurity Number Decedent's Name ~/-} L Q/~ ~ . C~UN7~R L( /1/) ~ ~ j ~ ~ o ~- ~ 7 ~"~- RECAPITULATION 1. Real estate (Schedule A) .......................................... ... i. © . 2. Stocks and Bonds (Schedule B) .............................. ... .. 2. ' ~ , 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. ... 3. ' o 4. Mortgages & Notes Receivable (Schedule D) ................ . ......... ... 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ..... ... 5. 8a f ~ 7 __' / ~-' 6. Jointly Owned Property (Schedule F) Separate Billing Requested .... ... 6. © , 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~_~.. Separate Billing Requested..... ... 7. 8. Total Gross Assets (total Lmes 1 7) ....... 8. $, / / ~ ~ `~ ( 9. Funeral Expenses & Administrative Costs (Schedule H) .................. ... 9. ~, ~ ~ ) ~ ~ b 10. Debts of Decedent, Mortgage liabilities, & Liens (Schedule I) ............. ... 10. ~ V tj ~~ 3 ~ / fo 11. Total Deductions (total Lines 9 & 10) ................................ ... 11. ~OQ~ 7l ~ 7~` , ~ ! 12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12 ~ O 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ...................... .. 13. ~~ (~ O CU C1 ~ 14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... .. 14. ' "' Q -- TAX COMPUTATION -SEE INSTRUCTIONS Fm~.,~ ~~~~~~~ ti -~ ~ ~~~ ~~ ~~~~~~~ ~ ~ OR APPLICABLE RATES ~~~~ ~ ~ ~ ~~~ ~~~~~ ~~~ ~~ 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ 15. 16. Amount of Line 14 taxable at lineal rate X .0 _ ' 16. ~j 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. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 15056052059 REV-1500 EX Page 3 File Number Decedent's Complete Address: o: / r~ a5" ~ 9 DECEDENT'S NAME DECEDENT'S SOCIAL SECURITY NUMBER STREET ADDRESS ~}b W,q~.Na-r ~o-morn Robb ~`IANo~e,a-i~-~ ~'~,~u.s~~ ,~ 2 L'~ AAA (.{ N>T CITY STAT A-2u s~E ~,~ zlP 1 `7o f 3 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) Q 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty Total InteresUPenalty (D + E) (3) ~ 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) b 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) (~ A. Enter the interest on the tax due. (5A) (~ B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5g) Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :.................................................................................... ...... ^ b. retain the right to designate who shall use the property transferred or its income : ...................................... ...... ^ c. retain a reversionary interest; or .................................................................................................................... ...... ^ d. receive the promise for life of either payments, benefits or care? ................................................................ ...... ^ [~ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ........................................................................................................ ...... ^ rd~ 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 January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (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 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 zero (0) percent [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 four and one-half (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 twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1502 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE ESTATE OF ~ ~ L P N ~ - GU t/,L~k, U rrJ FILE NUMBER All real property owned solely or as a tenant In common must be reported at fair market value. Falr market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F. ~~~ uw~o aNncc is neeuea, mserc aaamonai sneers or the same size) REV-1503 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF ~A Ll~N ~ - ~[;~ NI~2 U /`/~ FILE NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. (iT more space is needed, insen adtlrtlonal sheets of the same size) REV-1504 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNED~ILE C CLOSELY-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF ~} ~ fry e, ~ u/1/!~/LLt rn FILE NUMBER ~1 tJ3 039 Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. tir more space is neeaec, insert aooitional sheets of the same size) REV-157 EX+ (6-98) SCHEDULE D COMMONWEALTH OF PENNSYLVANfA MORTGAGES & NOTES INHERITANCE TAX RETURN RECEIVABLE RESIDENT DECEDENT ESTATE OF ~ ~ ~pN C, ~- ~ /'I/~ 2 (.(/'y~ FILE NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. 11f more space is needed, insert additional sheets of the same size) REV-1508 EX+ (6-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF ~~ ~ P N ~7~ C}u nl,d/, u ~ FILE NUMBER g ~' ~ ~_~ ~ 7 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH I plc ~An/K ('N~~,r!r//~ ,4~cou~ ~AI~N~E T~~SF~e,e~ ~, x/5.35 /ti/T© THt; ~s T~ ~ ,~ e~cu NT :~ l~~Fun/~ FRvm 8r-u~ ~2oss - /~lEni~~L rNSUQ,4NCE C~u~2r~~y ~~A ym ~; ~jFuNb F,~orn C~REM,4T7vn1 So~~~..r-y t~ ~A ~ m y ~A T~~2 ~avA r~o !-~~s ,'BoDy 70 /~urn,4-~v~ r y Gigs /~~(~v~TR-~ " TNT L~~7~~!~ `S~OC'tETy W~I.S ,q Ce~v117;N~'~t,`('~l' ,r~22,~-N~'~~N'T !l= 7f'~ I~EG15yR}' C~pt.r~b,N,;T ,4CC~~~T f-+<IS .~Oti'A 7~~c~J~ ~~~1, ~'~ /~ ~ ~o ~ o0 TOTAL (Also enter on line 5, Recapitulation) $ ~ d~ ~ ~ ~• '~~ (If more space is needed, insert additional sheets of the same size) REV-1509 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDI~LE F JOINTLY-OWNED PROPERTY ESTATE OF ' .~ ~ /CIE ~'~ , ~'..~~ ~~ 2 K ~ FILE NUMBER ~ ( o ~ c~~53`~ If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. j1~~.~Ntc B C. JOINTLY-OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET / OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST TOTAL (Also enter on line 6, Recapitulation) I S (If more space is needed, insert additional sheets of the same size) REV-~ 5'10 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF /'~.~ LP f=/ e. ~~ ~!p ,Q, U M FILE NUMBER ~ 1 ~ 3 0~~ :3 `3 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE ~.,N~ TOTAL (Also enter on line 7 Recapitulation) $ (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (10-06) SCNED~lLE M COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATNE COSTS RESIDENT DECEDENT ESTATE OF R.,q LPN ~?, r~cNl.~RU rYl FILE NUMBER Debts of decedent must be reported on Schedule L ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: n/'~ t[~. FUN~..A-L i-~CM ~, sNe~ ~ 95, ~p ~. Fc~.' TR RrVSpo~ i A ~rd1~ o f ,~ oDy 6i~~rw /I~.A ND2G~4,~. ~'A ~' [~st ~ 1 p /-~>E,QS/~! JV~fflIG~i- foe (~iLT~ ~6=!_S7R.X> ©8/TUARt ~s ~n/b ~iU~ ~~E'~TH C',~~er~FrC'A7ES~ B. ADMINISTRATIVE COSTS: /YlIL-~A~E~ ToLt_S; ~/VV~L!?P~S, ST~P~ ~Z ~~°' 1. Personal Representative's Commissions ; FOF; EXEf'xu rr`' IX AND LEC:A ~ GuA~eD1A ~ ~ OD . J U Name of Personal Representative(s) ~%Al~~ 1-~ ~ /Nr 5 Street Adjdress-~ 33 1^~' l'y(Af L~ ~{ V~nra ~ City LAN& N D~NC ~~1 19 C "F'~ State Zip Year(s) Commission Paid: ~UD 2. Attorney Fees - ~~y-1 ES /Vl A NA N A-nl, ESQ . - ~ ~'©,tl5 u c t,q ~"! vnl S ~ o~ $~. ~ o L.lNUS FEN~<<~, esq. ~-,SAFE.D~.PasrT /NV~v%a~y r cf-cf5.5o 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) n//,CE Claimant r Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees - ~U Of'~nl ~.ST~4TE. ~~ErrnQU QsFln~N r ~/4.Drh IlV1STR.~1?IJr< ~~~• ~~ C C~TS7 5. Accountant's Fees /11~jQ 6. Tax Return Preparer's Fees /f//,~( C€b!4 i. ~. Fl NA L ~7'cl,~-k'D fArrl /2 E/'o~eT To Cu rnBE,~ LA-Ni~ ~u N7~ /5• c~ d O~PNAN's ~r:.c~T' ~. ~TA7-a; Nn?rcES - TrtE PATa~~r N~~s a o~1. S l TOTAL (Also enter on line 9, Recapitulation) I $ ~ ~ ~ a /.• ~~, (If more space is needed, insert additional sheets of the same size) REV-~ 512 EX+ 112-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDtlLE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER 2 ~~ ~ _", Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. r~ (If more space is needed, insert additional sheets of the same size) R COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG, PA 17105-8486 September 17, 2007 DIANE M HAINES 533 W MAPLE AVE LANGHORNE PA 19047 Re: RALPH GUNDRUM CIS #: 120173421 SSN: 201-18-3742 Date of Death: 04/01/2007 Dear Ms. Haines: Please be advised that the Department of Public Welfare is attempting to recover the monetary value of any and all eligible assets in the subject estate. Although the amount in the estate may be considerably less than that which is owed to the Department, our claim is against the estate, no one else. Your responsibilities, as the primary next of kinladministrator/executor, is to advise the Department of any assets in the estate and to insure that the remaining money, after all funeral and administrative costs are deducted, is sent to the Department. The Department of Public Welfare maintains a claim in the amount of $106,753.76 against the above-mentioned estate. This claim is for restitution of medical assistance granted on behalf of the decedent for which the Probate Estate is now responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely $22,480.28, was incurred during the last six months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely $84,273.48, is to be entered as a priority Class 5.1 claim against the estate. Please acknowledge receipt of this letter in writing, providing any required information previously omitted pursuant to Title 55 PA Code ~ 258.4 by completing the enclosed form; and advise whether the Commonwealth's claim is admitted and when payment may be expected. If the estate contains real estate, please provide the full address of the property, including the zip code, copies of the deed and the latest tax assessment, as well as a current appraisal, if available. When the estate accounting and inheritance tax forms are complete, please provide copies. If you have any questions concerning estate law and procedures, please consult legal counsel. Sincerely, ~r'~~~ Kelly J. Snider TPL Program Investigator 717-214-1861 717-772-6553 FAX Enclosure Diane Haines 533 W. Maple Avenue Langhorne, PA 19047 215-752-3338/267-980-3534 cell October 14, 2007 Commonwealth of PA-Dept. of Public Welfare, Bureau of Financial Operations Division of Third Party Liability, Estate Recovery Program ATTN: Kelly J. Snyder PO Box 8486 Harrisburg, PA 17105-8486 Re: Estate of Estate of Ralph C. Gundrum CIS # 120173421 SSN 201-18-3742 DOD: 04/0112007 Dear Ms. Snyder: Enclosed please find the completed Decedent's Assets Itemization Form as requested. As Executrix and formerly Legal Guardian of my father's estate, the following is the estate accounting to date: Assets: • PNC Bank checking account transferred into the estate account • Refund from Blue Cross quarterly payment • Refund from Cremation Society of PA (my father donated his body to Humanity Gifts Registry -this was a contingency arrangement if the Registry could not accept his donation) Di sbursements/bil is Cumberland County Orphan's Court Final Guardian Report 6/4/07 James Manahan, Esquire Estatelprobate consultation 7/9/07 The Patriot News -estate notices 7120107 $ 6,815.35 Total Assets $ 8,117.72 262.37 1,040.00 $ 15.00 139.40 209.81 Commonwealth of PA -Dept. of Welfare Page 2 • Neill Funeral Home, Inc. 7/23/07 495.30 (Transportation of body from Carlisle to Hershey Medical for gifts registry, obituazies, and five death certificates) • Linus Fenicle, Esquire 9/29/07 445.50 (attorney to inventory safe deposit box and letter to Department of Revenue) • Diane Haines, Executrix 10/13!07 366.62 (reimbursement of $80. Cumberland County Register of Wills fee to begin estate process, and administrative costs including mileage, tolls, envelopes, and stamps • James Manahan, Esquire ?? (2°d meeting with attorney regarding DPW letter and finalizing estate -bill not yet received) Disbursements to date $ 1,671.26 Net estate amount remaining $ 6,446.46 As stated above, I was my father's legal guardian for nearly four years. During those years I spent significant time managing and overseeing his care, finances, preparing annual guardian reports, dealing with legal issues, applying for his county assistance, and personal services. I never took any form of compensation for my time. I want to take $450 to $500 far my combined services as executrix and legal guardian. Adding the outstanding fee for the second meeting with Attorney Manahan, which I approximate at $150, to the $500 for my services, leaves an approximate balance of $5,800 for your claim. Please advise me of your response to my xequest. Sincerely, Diane Haines Executrix Enclosures KJS COMMONWEALTH OF P£NNSYLVANW DEPARTMENT OF PUBLtC WELFARE BUREAU OF FINANCJIL OPERATIONS DMSION OF THIRD PARTY LfABiLITY ESTATE RECOVERY PROGRAM PO 80X 3x86 HARRISBURG. PA 17tOS-3486 Pursuant to notification requirements set forth in Title 55 PA Code § 258.4, completion of this form is requested in order for the Department to ascertain information and viable assets of this estate. Please complete both pages of this form and return to the address listed above, as soon as possible. For items that do not apply, please put N/A in the space provided. Decedent's Infonmation: -~~ Decedent's Name: ~ ~~ ~.~ ~ ~ ~ '~ M ~~ Y - .CIS. ~ ~Y:, +~ ~ bar : U l - / ~ 3 '7 4 ~ , * ~. . -.> {~ -- y .:, ~ ~ E ~`~- • ~ Y a I r _ U ( i ~~l '~G'C1~ f~ ' • ' ~ ~ ~ . ~~ /l ~A.1%C~,~C 'vt!/h LP.i,i i - ~%(' I~ ~ P ~^ L. r~ F. L./ S L C_. f' ~ ~ ~- '. `~< .. ?Yt ~..tr~. _, ' . I ~ 1. f. ._. /"`• ~~ 1 t t 7- ~ -~ 8 ~-- ~ (data t nts} ;~ , ; __.____..__~-- i IZepr@S6ntAtiVe'8 Information (Executor /Administrator /Next Of Kin }: ~~-Repres~ntative's'~lame: ,q ' ~ ~.~ n> ~ ~ ~ /A , , , N F - ~,. ~ : { Relatlonsllp~~'o Decedent: ~X~ t' u 7 n ix ~~ f1 rrl v fr r F ~;? ~~~~ ~~-,~ ox rest Address 5~3 ~} flan P ~ E ~v~ ~ U .~ ~ ~` f ; -City; ~State,~ip Code: L ~ v; Daytime~Phone Number: ~, i, n - ( ,. ~ ~ ) ~~ ;; ~ - j J ~ ~ ` ~, Attorney's Information: Law•Firm Name: ~"r ,~ NS ; ~t N ~ ^,'~.a v •~ t~ -1 ti, ~ ~. ~' i Attomey's Name: ~.1~1rY', ES ~ ~ ~ri';1,~,..~ :j. +~,~ P O Box And/Or Street Address: ~ ~~ City, State, Zip Code: ~ j z~ k;>; r ,,,,, ~~~ ~` . ~ -% Phone Number: ~ ~ ~ :• ,~- _ ~ ~~ ~;,,. ~. Fax Number: ~ ~ _' i r ~ _ ~ _ Decedent's Assets Itemization Form Item Information Date of Death Current Value Value Propert}f/ Real Estate: Street Address: provide copy of deed ~ ' City, State, Zip: f, ~.~ /L $ i / ~ r , $ , i __ -. Owners as listed on Deed: r ~,I i ~ '~~~,~ ~ ~ ,~~ Circle One: "Tenants in Common" ~ ~~ ~~.~ 'Joint Tenants with Right of Survivorship" _. Tenants by the Entirety" ' `~ ~~n COitsr2 ~ ~ Account#~~'~`~~39-~`)/~ ~~r~~ ~ Sb `SI~,~ 5~ 4~~F`¢ i ~ I ~ ~ ~, ~ ~~~ ~ ~~ Account # '` ~ ~ _. , ' I ~ I !' ~I _ Account # ~ _ $ _ ` - I `.Indicate a Joint account by placing a "J" on the line provided I Account # ~ f ~ i ~ ~ ,~? _.~. ,~+ { ~~ ---- Account # ~~~- F°u,~'at ~~ j ~ ~ ~ ~ <J~ .~~d ,, ~: ~ -~ M $ Account # ` I _ __r ____ _.._____.___~, __._____ ~ i ~&~~ Policy # ~ ~ j ~ R' y- ~" ' ~ ~ ~ ~ - N i B fi , ~ ~ ~ ~ : ~ ame } ~ ary ene c j ~~ ~ ~ ~-,~. ~~ ~~ - Policy # ! U - ~ i1~ ` ' I ~ ! ' ~ ! , } ~;~ f - t .~~~`~ i~: r ' ~ Beneficiary Name i S ~; S J~ I~ j ~ 4 :'f. aC'.2_ ~1^. .Y~~ ~ PoltCry tf ~ ,/ ~ ~u `s t Beneficiary Name I Stocksi~ ondsl-Other:-= - __ __--_._~ ~~- ~ `7 ---- -_ - -_ _ R~ ND ~Ror~ p~ ~u ~. t',~ a.~s ~ u ~ r-'rf~~ I ~ .~t/ ~t• ~ - y - ~ - . _~ , ~':?o#ai Estate~Va{ue` ~ $ ~, I J ;? ?,~ ~ ~ (,;'.{-~'~• ~b~ Wilt the decedent's estate be probated? ~_Yes No (Probate is necessary when there are assets in the decedent's name only. Assets held jointly and assets that have designated living beneficiaries usually do not require probate.) Is a small estate petition being filed? Yes No (A small estate petition, a form of probate, can be flied if the estate assets are S25.000 or less 1 If you have questions regarding estate or probate law, please consult legal counsel) an estate attorney. I ACKNOWLEDGE THAT THE INFORMATION 1 HAVE SUPPLIED ON THIS FORM IS SUBJECT TO THE PENALTIES SET FORTH !N 18 PA C.S. 4904. (relating to unsworn falsification to authorities) Name fFlease print c'eariy! S cra'ure Pease s.tin '^ "K'. ^-r' .,,,:.. -.w :; ..~ -~. ~. A~~ .. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG, PA 17105-8486 October 23, 2007 DIANE M iiAINES 533 W MAPLE AVE LANGHORNE PA 19047 Re: RALPH GUNDRUM CIS #: 120173421 SSN: 201-18-3742 Date of Death: 04/01/2007 Dear Ms. Haines: This letter is to advise you that according to the information you provided to our office regarding the assets of the above-referenced estate, the Department of Public Welfare will accept the balance, namely $5,796.46 remaining in the estate for payment of our existing claim. Please have the check made payable to the Department of Public Welfare and forwarded to my attention at the above address. Your cooperation in resolving this matter is appreciated. Sincerely, ~~~LI~~ Kel1v J. Snider TPL Program Investigator 717-214-1861 717-772-6553 FAX COMMONWEALTH OF PENNSYLVANIA DEPARTMENT Of PUBLIC NIELFARE BUREAU OF fINANCiAL OPERATiCN5 DNiS10N Or' THIRD PARTY LL"+96L~TY ESTATE RECOVERY ?ROGRAM PO BOx 3t?6 ~ARRISRLRG PA. "+;S-?cS Re : t%~LPF? Gii~i~RvM CIS #: 1.20173921 SSN: 2^v1-18-3742 _- -~-- _ _.__ ~_..:-e-ra~~rer_-~~ es___~. _.__.. __~_ec__ ~as~.=~~ _ _~ _:e ~al.:e YOLir GCOLJer.,...~On ~n reSG~i^g "._S ....=~~eY ~S ^v~reCia~2d. Sincerely, i{elly J. Snider TPL Program Investigator 717-214-1861 717-772-6553 FAX REV-t513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF ~~}~~ (?, [yi.1NJJ1-~!.~'y~ NUMBER I of c~ II SCHEDULE J BENEFICIARIES NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not List Trustee(s) TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] mQ,~y ~~~~E~G 'a`f35suns~ LAn/r:, ~~• s/5T£k yam, ~ ~7~~ ~~N~/ ~//bQu rn -~c`~ f, 5rH ~4VF,, ~4PT~ 3 .~RD7ft~/.; L,4av~~ sTEk.-, O1-~ ~313D-~ jpD Lu,~-~/~_ ~'u N.~2Lc rn - f~3 `~ /t/~ DEri~NC~,. sr- ~~4 uGftT~ ~,4corn~, h/~ 9~i~ob ~~ % ~ .~~~N~ I-~~~nr~s -.~3~ ~~ rn,~p~~ ~ v~ 7>~I G(ENTiE2 LAi/6a~aan~E, ~~ ~°`~7 FILE NUMBER 6 3 0~ ~~ AMOUNT OR SHARE OF ESTATE .~ oao . coo o00 • no ,~D°Jn oFf7,~n1A1NaEJZ G'F ~STf1TE ~o~o GF RE./N~4~Np~2 6F FST~i TE. ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS r~,~-Nx «n~rat.#~l F-~R-~ C+vr-~-~q-ivy ~1~~SL3urzts La!oN~ C,~ua4 ~UUD• 00 /, ooD. oa TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I a ~ ~ p0O - G~ D (If more space is needed, insert additional sheets of the same size) RALPH C. GUNDRUM i, Raiph C. Gundrum, of 10 East South Street, Box 42, Franklintown, York County, Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this to be my Last Will and Testament, hereby revoking and making void all previous Wills and Codicils heretofore made by me. FIRST I order and direct my personal representative hereinafter named to pay all of my just debts, funeral expenses and expenses involved or connected with the administration of my estate as soon after my death as is reasonably possible. However, my personal representative need not accelerate and pay those unmatured obligations which, in his, her or its opinion, it might be proper and more advantageous to retain or renew and pay as they become due and payable. It is my desire to donate any and all organs and/or body parts to Humanity Gifts andlor any other organization of similar service as long as my estate incurs no charge for these donations. The rest of my remains shall be cremated. I authorize my personal representative in his, her or its sole discretion, to dispose of my ashes as they deem fit, and to expend sums from my estate for this purpose. SECOND I give, devise and bequeath the sum of five thousand ($5,000.00) dollars to my sister, MARY GOLDBERG of 2201 Carlisle Road, York, Pennsylvania providing that she survive me by sixty (60) days. _ ,., r~ _._ __ -- - - ~~. ZhF+~h; ~.. I give, devise arid bequeath the sum of five thousand ($5,000.00) dollars to my brother, HENRY B. GUNDRUM of Avondale, Colorado, providing that he survive me by sixty (60) days. I give, devise and bequeath the sum of five thousand ($5,000.00) dollars to the FRANKLINTOWN FIRE COMPANY. give, devise and bequeath the sum of one thousand ($1,000.00) dollars to the DILLSBURG LIONS CLUB. I give, devise and bequeath the rest, residue and remainder of my entire estate together with all insurance proceeds thereon of whatever nature and wheresoever situate in equal shares to my daughters DIANE M. HAINES and LUANE D. GUNDRUM, who survive me by sixty (60) days, per stirpes. FOURTH My executor and trustee are authorized and empowered to exercise from time to time in his, her or its sole discretion and without prior authority from any Court, in respect of any property forming part of any trust hereby created or otherwise in its possession hereunder all powers conferred by law upon trustees or executors and the testator intends that such powers be construed in the broadest possible manner. FIFTH I nominate, constitute and appoint my daughter, DIANE M. HAINES, Executrix of this my Last Will and Testament. In the event DIANE M. HAINES is deceased, unable or unwilling to serve or shall cease to serve for any reason whatsoever, then I nominate, constitute and appoint LUANE D. GUNDRUM, to serve instead. I direct that my personal representative shall not be required to give or post bond for the faithful performance of his, her or its duties in this or any other jurisdiction. ,_.= ~ SIXTHb - I hereby declare it to be my expressed desire that my personal representative employ treason Law Offices of Cumberland County, Pennsylvania, for legal advise and assistance regarding this my Last Will and Testament, they having considerable knowledge of my affairs, including additional documents, and my views and wishes respecting any matters that may arise at the probate of this instrument, the administration of my estate, and the execution of the powers herein mentioned. IN WITNESS WHEREOF, I have hereunto set my hand to this my Last Will and Testament this ~ ~ day of Imo,;;. , + , 2002. ,~ ,~ I/ / .i -• Witness RALPH . GUNDRUM `_ ~ ~, 1/1~itn s COMMONWEALTH OF PENNSYLVANIA COUNTY OF SS 1, Ralph C. Gundrum, the Testator whose name is signed to the attached or foregoing instrument, having been duly qualified according to the 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. ~/ C ~' ,. RALPH C. GUNDRUM Sworn or affirmed and acknowledged before me by Ralph C. Gundrum, the Testator, this ~'~ t day of r-~ ~,~~ ~ ,` , 2002. -~--- -- "Notary Public , ~~ IYotariai Sea! Lisa M. treason. Notary Pub ' Carlisle i9oro, Cum4erland Qpr~y '_ ^~y Commission Ex~..,~s Sept. 9, 26p2 hrr~ut-~v ~ ~ COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF We, .:. ,~,~ E!,~c.~~;~, ~ and ~~:. <, ~ ~ ~~ti .,.~ , the witnesses whose names are attached to the foregoing document, being duly qualified according to the law, do depose and say that we were present and saw Testator sign and execute the instrument as his Last Will and Testament; that he signed willingly and that he executed it as his free and voluntary act for the purposes therein expressed; that each subscribing witness in the hearing and sight of the Testator signed the Last Will and Testament as witnesses and that to the best of our knowledge the Testator was at the time 18 or--more years of age, of sound mind and under no constraint or undue influence. .~/ ,.~ IJ~ 1 ~ (f L Sworn or affirmed and subscribed before me by ~ ~ ~'' ~' ~ "~ ~ ~~ - and _ , _ ~ . ~ . this day of : `, ~; , 2002. ,,- , Notary Public ;' Notarial Seal Usa M. treason. ~Y Public Carlisle t3oro, Gurrrberland Gour-ty Niy Gommissio~, Frpirag Sept. 9, 2C`^ REV-7514 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE K LIFE ESTATE, ANNUITY & TERM CERTAIN heck Box 4 on REV-1500 Cover Shee ESTATE OF FILE NUMBER This schedule is to be used for all single life, joint or successive life estate and term certain calculations. For dates of death prior to 5-1-89, actuarial factors for single life calculations can be obtained from the Department of Revenue, Specialty Tax Unit. Actuarial factors can be found in IRS Publication 1457, Actuarial Values, Alpha Volume for dates of death from 5-1-89 to 4-30-99, and in Aleph Volume for dates of death from 5-1-99 and thereafter. Indicate the type of instrument which created the future interest below and attach a copy to the tax return. ^ Will ^ Intervivos Deed of Trust ^ Other NAME(S) OF LIFE TENANT(S) DATE OF BIRTH NEAREST AGE AT DATE OF DEATH TERM OF YEARS LIFE ESTATE IS PAYABLE Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Lite or ^ Term of Years 1. Value of fund from which life estate is payable ..........................................$ 2. Actuarial factor per appropriate table ................................................ . Interest table rate - ^ 3 1/2% ^ 6% ^ 10% ^ Variable Rat 3. Value of life estate (Line 1 multiplied by Line 2) ........ .............................$ NAME(S) OF LIFE ANNUITANT(S) DATE OF BIRTH • NEAREST AGE AT DATE OF DEATH TERM OF YEARS ANNUITY IS PAYABLE ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years ^ Life or ^ Term of Years 1. Value of fund from which annuity i payable ............................................$ 2. Check appropriate block below nd enter corresponding (number) ......................... . Frequency of payout - ^ W kly (52) ^ Bi-weekly (26) ^ Monthly (12) ^ Quarterly (4) ^ emi-annually (2) ^ Annually (1) ^ Other ( ) 3. Amount of payout per pe od ........................................................$ 4. Aggregate annual pay ent, Line 2 multiplied by Line 3 .................................. . 5. Annuity Factor (see ' structions) Interest table rate ^ 3 1!2% ^ 6°I° ^ 10% ^ Variable Rate 6. Adjustment Fact (see instructions) 7. Value of annuity - If using 3112%, 6%, 10%, or if variable rate and period payout is at end of period, calculation is: Line 4 x Line 5 x Line 6 ..........................$ If using variable rate and period payout is at beginning of period, calculation is: (Line 4 x Line 5 x Line 6) + Line 3 ..................................................$ NOTE: The values of the funds which create the above future interests must be reported as part of the estate assets on Schedules A through G of this tax return. The resulting life or annuity interest(s) should be reported at the appropriate tax rate on Lines 13 and 15 through 18. (If more space is needed, insert additional sheets of the same size) Diane Haines 533 W. Maple Avenue Langhorne, PA 19047 215-752-3338-home 267-980-3534 -cell November 26, 2007 Cumberland County Court of Common Pleas ATTN: Register of Wills Cumberland County Courthouse 1 Courthouse Square Carlisle, PA 17013-3387 Re: Estate of RALPH C. GUNDRUM Dear Sir or Madam: Enclosed please find the Inheritance Tax Return Resident Decedent form with attachments and duplicate set in the above matter. Please contact me with any questions. Sincerely, ~-~ 11 , ~. ~= Diane Haines Enclosures - 2 ~~ 0 ~~cao°~ ~or~~ch $o ~ °~oo ~µr 1 i _~ -~+ V ^' O J a° ~~ ,,AA o tVtA/ V• Q J `V ~~r/~ V/ ~_ a v~ d .. ~ yo ~~ ~~ ~~ M ~ ch T ~_ ~ n T . ~ O Q a= W = J y- a ~_ N Q = V ~~ ~.. % L._. Y "_ ~ f_ ~~. r `,` ~ ~__ .; ~ C) L2.. C.../ CJ ~. ,~„ ~.~! ~ r. C~ _ ~ / :.- [L ~_ ' W ~ -~ _ -" L7 ~ ~ `_ ~ ~ _. .. C7 tV ~~~~ <_ ^~ f ~^ R •~ t~ ~ _. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX *' DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 03-10-2008 GUNDRUM 04-01-2007 21 03-0539 CUMBERLAND 101 APPEAL DATE: 05-09-2008 ( See reverse side under Objections) Amount Remittedl I MAKE CHECK PAYABLE AND REMIT PAYMENT REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION PO BOX 280601 HARRISBURG PA 17128-0601 11 l"t.ot 1''). HtR ""I'II~"' r:: '_~ ,,)U ORHJ!; DIANE HAINES-:!;, 533 W MAPLE "AVE LANGHORNE ,1:=; PA 19047 REV-1547 EX AFP (06-05) RALPH C TO: CUT ALONG THIS LINE ..... RETAIN LOWER PORTION FOR YOUR RECORDS 4- ------------------------------------------------------------------------------------------- REV-1547 EX AFP (03-05) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF GUNDRUM RALPH C FILE NO. 21 03-0539 ACN 101 DATE 03-10-2008 T AX RETURN WAS: (X) ACCEPTED AS F I LED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 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 ( ) CHANGED (1) (2) (3) (4) (5) (6) (7) .00 .00 .00 .00 8,117.72 .00 .00 NOTE: To insure proper credit to your account. submit the upper portion of this form with your tax payment. (8) _ 8,117.72 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. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate SUbject to Tax If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will reflect figures that include the total of Ahh returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate 16. Amount of Line 14 taxable at Lineal/Class A rate 17. Amount of Line 14 at Sibling rate 18. Amount of Line 14 taxable at Collateral/Class B rate 19. Principal Tax Due TAX CREDITS: PAYMENT DATE NOTE: RECEIPT NUMBER DISCOUNT (+) INTEREST/PEN PAID (-) (9) ClO) 2,321.26 106,753.76 (11) _ Cl2) _ Cl3) _ Cl4) _ ]D9.n75.D~ 100,957.30- .00 100,957.30- Cl5) .00 X 00 = .00 .00 X 045 = .00 .00 X 12 = .00 .00 X 15 = .00 Cl9)= .00 AMOUNT PAID Cl6) Cl7) Cl8) TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE .00 .00 .00 .00 * IF PAID AFTER DATE INDICATED. SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $I, NO PAYMENT IS REQUIRED. r~ IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DU~ 1 A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) Pa. O.C. Rule 6.12 STATUS REPORT REGISTER OF WILLS OF CtA IY1 /jIC I< LAN t~ COUNTY, PENNSVL VANIA Date of Death: RALPI-J C, 04- /01/3..00'7 f I G-u rJ b~Ll rv) Name of Decedent: File Number: 'd--J - 07- 0,539 Pursuant to Pa. O.C. Rule 6.12, 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: . . . . . . . . . . . . . . . . . . .. JJfVes D 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? . . . . . .. OlIVes ONo b. The separate Orphans' Court No. (if any) for the personal representative's account is: I filA Date 1''( C~/0, ;; 00 8' c. Did the personal representative state an account informally to the parties in interest? ............................... _Ves 0 No Sti-t. ATTACl-{I!:-D d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. I (Al~ ~ Signature of Person Filing this Form ~;Z :~,i i~J ::}! , ~... ~ Capacity: ~personal Representative 0 Counsel ]) lA II! E. ;..fA I rJ E 5: Name of Person Filing this Form 08RW, fVllt(';Lf:...AJf. Address ~ LA rJ G H-c K,.Jf \ 11\ I q c 41 d-~'7 - q go -3 53 ~ (uzJt') Telephone ,. -' Form RW'IO rev, JO:JJ06 ~ BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION PO BOX 280601 KARR1SBURG PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX REV-1S47 EX AFP C06-05) DATE 03-10-2008 ESTATE OF GUNDRUM RALPH C DATE OF DEATH 04-01-2007 FILE NUMBER 21 03- 0539 COUNTY CUMBERLAND ACN 101 APPEAL DATE: 05-09-2008 ( See reverse side under Objections) Amount Remittedl I MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE -+ RETAIN LOWER PORTION FOR YOUR RECQRtlS ... +-- REY:is47-Ex-AFpwcoi:osj-HorlcE-oF-IHHERlrANcE-TAX-APPRAIsEMEHr:-ALLOWANCE.OR--------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF GUNDRUM RALPH C FILE NO. 21 03-0539 ACN 101 DATE 03-10-2008 DIANE HAINES 533 W MAPLE AVE LANGHORNE PA 19047 TAX RETURN WAS: (X) ACCEPTED AS FILED CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 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 (1) (2) (3) (4) (5) (6) (7) .00 .00 .00 .00 8,117.72 .00 .00 (8) NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment. 8.117.72 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funel'al Expenses/Adm. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Not Value of Tax Return 11. Charitable/Governmental Bequests; Non-elected 9111 Trusts (Schedule J) 14. Not Value of Estate Subject to Tax (9) (0) 2.321.26 106,753.76 01> (12) 01> (14) 109.075.02 100,957.30- .00 100,957.30- If an assess.ent was issued preViously, lines 14, 15 and/or 16, 17, 18 and 19 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate 16. Amount of Line 14 taxable at Lineal/Class A rate 17. Amount of Line 14 at Sibling rate 18. Amount of Line 14 taxable at Collateral/Class B rate 19. Principal Tax Due T X C NOTE: .00 X DO .00 .00 X 045 = .00 .00 X 12 = .00 .00 X 15 = .00 (9)= .00 AMOUNT PAID OS) (16) (7) (8) DATE I NUMBER o NT (+) INTEREST/PEN PAID (-) TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE .00 .00 .00 .00 . IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS LESS THAN .1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A R~I=UNn~ !:::I=I= R"I=VJ:Dc:.s: c:.Tn~ nr TU'f~ a=no.. l:'"nD TLlC!oTDIII"TTnuC-'" " Diane Baines 533 \V. \taple Aycnue Langhorne, PA 190..P 215-752-3338 267-980-353'" cell October 21. 2007 Ms. Mary Goldberg 2435 Sunset Lane, Apt. #1 York. PA 17408 Re: Estate of Ralph C. Gundrum Dearl\tts.Goldberg: The administration of Ealph C. Gundrum is n~arly complete. The followil1!; is an accounting of the Estate: Total Assets S~.117.72 Disbursements/bi lis: . Cumberland County Orphan' s Court Final Guardian Report 6/..V07 . James Manahan, Esquir Esta(elprob~lte consultation 7/9/07 . The Patriot News - est;lk' Ih}[ices 7!2()()-:' . Neill Funeral Home, Inc. 7/23/07. (Transportation of body from Carlisk to Hershey r'v1edical for gifts registry, obituaries and death certificates) . Linus Fenicle. Esquire 9/29/07 (attorney to in\'cntory safe deposit bo\: and letter to Department of Revenue) . Diane Haines, Executrix 1013/07 (reimbursement of estate process t~e and administrati\'e COS1::;) . James Manahan, Esquire (2nJ meeting with attorney regarding DP\\' It:tt~r and finalizing estate - bill I1l)t yet receiwd) . Department of Welfart: claim lien on Estate s ! S.OO ! 39...+0 =oq.~ i -+95.30 .f-f5.50 366.62 '1') 5]1)6.753.76 .-\n1(\unt remaining for hendiciaries: S -0- ACKNOWLEDGEMENT AND RELEASE 1. MARY GOLDBERG, named as a beneficiary in the Last Will and Testament of Ralph C. Gundrum, do hereby acknowledge and accept the Estate accounting as received in the October 21, 2007 letter from Diane Haines. Executrix, and do hereby release Diane Haines. Executrix, from any further obligation. Date: .. -' ~'- 'c:'/ (:;:- d"--~:"'~:' ,:...:L/ . ( ~.. rT M.A.RY/GOI..DBERG ;' ACKNOWLEDGEMENT AND RELEASE I, R.6BEA r ft ~EAH r)f . as a representative of the Franklintown Fire House. named as a beneficiary in the Last Will and Testament of Ralph C. Gundrum. do hereby acknovvledge and accept the Estate accounting as received in the Octoher 2] , 2007 letter from Diane Haines. Executrix. and do hereby release Diane Haines. Executrix. from any further obligation. "r\ c2 /7,/"- / I r'-- /) I' "I ,~,/ I /. / / ~~~~7 (:/~,c-, RepresentatiJe. Franklintown Fire House I "'7 "",,- Date: ;6 r- .,...... ) ACKNOWLEDGEMENT AND RELEASE 1. HENRY GlJNDRUM. named as a beneficiary in the Last Will and Testament of Ralph C. Gundrum. do hereby acknowledge and accept the Estate accounting as received in the October 21 . 2007 letter from Diane Haines, Executrix. and do hereby release Diane Haines, Executrix. from any further obligation. Date: / .i J. j/ I /C I . f on " ~) _ ,'.. r'~ .~:,.._ L' / _~f,\ ;~ ,:'....__f . "". / /=,::;1\.._. _ / , .' " '",,.. -. \.. -._- 1''-....>.-1..(./~./ -:--r:- :/ --~--- "'--.} /<(j ,'-/ " HENR~:DlJNDRUM .-' ACKNOWLEDGEMENT AND RELEASE 1. i.'J ~\~ ....i.1 V{" L .t~'.'; !.::" , as a representative of the Dillsburg Lions Club. named as a beneficiary in the Last Will and Testament of Ralph C. Gundrum, do hereby acknowledge and accept the Estate accounting as received in the October 21. 2007 letter from Diane Haines. Executrix, and do hereby release Diane Haines, Executrix. from any further obligation. Date: .:,2tl .../' // L 1..// .A... Representative, Dillsburg iibns Club ACKNOWLEDGEMENT AND RELEASE 1, LUANE GlJNDRUM, named as a beneficiary in the Last Will and Testament of Ralph C. Gundrum, do hereby acknowledge and accept the Estate accounting as !'ecei\'t'~d in the October ~ L 2007 !~tter from Di:1n~ Haines. Executrix. and do hereby release Diane Haines. Executrix. from any further obligation. " r t /1/ ,A /i., ,....-'1 Date: v\:" L{{/ ~/ I ,f fv------.- :cJ Beneti~iary Letter October 21. 2007 Page 2 For the purpose of closing the Estate. please sign the enclosed Acknowledgement and Release and retum to me in the enclosed. self-addressed stamped em"eiope. If you haw any questions. please feel free to call me at 215-752-3338. Sincerely. ..-f / r ,I , ! i . V.~ l--d-'t_i../y,~V Diane Haines Executrix Enclosun: