The URL can be used to link to this page

Home My WebLink About07-22-11 (2) 1505610143 EX (01-10) REV-1500 OFFICIAL USE ONLY _ PA Department of Revenue pennsylvania County Code Year File Number Bureau of Individual Taxes DEPARTMENT OF REVENUE PO 60X.280601 INHERITANCE TAX RETURN 21 10 055 9 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 196 14 3221 05 11 2010 12 15 1922 Decedent's Last Name Suffix Decedent's First Narne MI SHOTSBERGER HILDA M (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First NamE; MI Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 1. Original Return ~ 2. Supplemental Return 4. Limited Estate ~ 4a. ~ uture Interest Compromise date of death after 12-12-82) g Decedent Died Testate ~ ~• (Atta ch Copy Hof Trust)a Living Trust (Attach Copy of Will) 9. Liti ation Proceeds Received g ~ 1 p. Spousal Povert Creditl(date ~f death between 12-31 ~J1 and -1-95 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required ~ 8. Total Number of Safe Deposit Boxes 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number J~AME S D BOGAR '71.7 7 3 7 8 7 61 First line of address ONE WEST MAIN STREET Second line of address City or Post Office State SHIREMANSTOWN PA Correspondent's a-mail address: jbogar@bogarlaw.com ZIP Code REGISTER OF ~ USE OI ~ C7 r ~" - ~ ~~~ i~ N ~~~ ~ -n ::~ - ~ ~ FILED DATE ~~"~ ~~ r~t ~ ~ t r ~J -- 4"~~ ~, y ! 1 •f t G ; ~- ,~ ~; F::~~~ t. - : ~-~ ~~ 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 oeuet, 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. ~SL6NATURE OF P R O RESPONSIBLE FOR FILING RETURN ~ DATE V Mary E. Shotsberger _ ~ / ~-1 ~ 1a ~ 1 ADDRESS 3943 rookrid a Drive Mechanicsbur PA 17050 SIG U OF PR R OTHER THAN REPRESENTATIVE DATE ,,, _ ,~ , JLt~ James D. Bogar ""1 ~ ~~ ~Zp~ ~ One West Main met, Shiremanstown, PA _ ------..- Side 1 1505610143 1505610143 J 1505610243 REV-1500 EX Decedent's Name: $t10tSberger, Hilda M. RECAPITULATION 1. Real Estate (Schedule A) ....................................................................................... 1. 2. Stocks and Bonds (Schedule B) ............................................................................. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)......... 3. 4. Mortgages & Notes Receivable (Schedule D) ........................................................ 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............... 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6. 7. Inter-Vivos Transfers & Miscellaneous ion; Probate Property (Schedule G) u Separate Billing Requested............ 7. g. Total Gross Assets (total Lines 1-7) ..................................................................... 8. Decedent's Social Security Number 196 14 3221 138,587.40 124,751.54 244.55 263,583.49 36,879.74 9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... 9. 30,848.53 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. 10. 67,728.27 11. Total Deductions (total Lines 9 & 10) ................................................................... 11. 195,855.22 12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12. 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ............................................... 13. 195 , 855.22 14. Net Value Sub'ect to Tax Line 12 minus Line 13 ••• 14. TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 15. (a)(1.2) X .00 16. Amount of Line 14 taxable 195 , 855.22 1s. at lineal rate X .045 17. Amount of Line 14 taxable 0 . 0 0 17. at sibling rate X .12 18. Amount of Line 14 taxable 0 , 0 Q 18. at collateral rate X .15 19. Tax Due .................................................... ............................................................ .. 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 1505610243 1505610243 0.00 8,813.48 0.00 0.00 8,813.48 REV-1500 EX Page 3 File Number 21-10-0559 _ _ _._~~~_ ~._~.-~_a_ w..1..1......~.. DECEDENT'S NAME Shotsberger, Hilda M. STREET ADDRESS 2910 Morningside Drive CITY STATE ZIP Camp Hill PA 17011 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) 8,813.48 2. Credits/Payments A. Prior Payments 9,534.00 B. Discount 440.67 Total Credits (A + B) (2) 9,974.67 3. Interest (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) 1,161.19 Check box on Page 2 Line 20 to request a refund 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) Make Check Pa able 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 :............................................................................... ^ 0 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? ............................................................ ^ x 2. If death occurred after Decembe'12, 1982, did decedent transfer property within one year of death without ^ ^ receiving adequate consideration ..................................................................................................................... 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?....... ^ ^x 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. ,, ; a ;. ,,~-~ k ": ~ ': ~. ~ iht~`d~ .' ,..:,~ E ~~'~`~~~ ';~.'?.~ ~ r 4,r, ~~ '~~~'` ~L >`y ,} t~•r" ~ a+.,~y For dates of death on or after July 1, 1994 and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0 percent [72 P.S. §9116 (a) (1.2)]. . The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiarie:> is 4.5 percent, except as noted in 72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1)]. . The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116 (a) (1.3)]. A sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Rev-1502 EX+ (11-08) SCHEDULE A REAL ESTATE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ESTATE OF FILE NUMBER Shotsberaer, Hilda M. ~ 21-10-0559 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a welling 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. Attach a copy of the settlement sheet if the property has been sold Include a copy of the deed showing decedent's interest if owned as tenant in common. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Real Estate -All that certain piece or parcel of land being known and numbered as 2910 138,587.40 Morningside Drive, Camp Hill, Pennsylvania. The property was acquired by Henry Shotsberger and Hilda Shotsberger, his wife, by Deed dated November 30, 1978 and recorded December 1, 1978 in the Cumberland County Recorder of Deed Office in Deed Book "E", Vol. 28, Page 361. A copy of said Deed is attached hereto and incorporated herein. The said Henry Shotsberger died August 9, 1997, whereupon full and complete title to the within described real estate became vested solely in Hilda Shotsberger, the Decedent herein. The total assessed value of this real estate is as follows: County Assessed Value $109,990.00 x Common Level Ration 1.26 = $138,587.40. TOTAL (Also enter on Line 1, Recapitulation) 138,587.40 (If more space is needed, additional pages of the same size) Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule A (Rev. 11-C1c~l 201-CT-Warranty Deed-Short Form-Act 1909-Double Sheet Henry Hall, Inc., Indiana, Pa. ~~t~ ~A ~ ~~ RCCCR~Eu-o=rl%[ OF F!E CUtdf~,ERL,1F,~ CO:.!NT,'f PENNSYt.'vd?vIA ~~EC ~) ~ Ql C~~'Z~ MADE THE ~ `~ ~.Vl day of ~-~~-~-'-~''~ in the year ~ ~ ~ ~ o f our Lord one thousand nine hundred seventy -eight (19 7 8 ) BETWEEN THELMA G. GRAHAM, by her Attorneys-in-Fact, Irene G. Critchley and Thelma G. Rathfony duly constituted anartctofgthe by virtue of a Power of Attorne dated May 9, 1978, p y first part, Grantor , and HENRY SHOTSBERGER and HILDA SHO7'Sp,ERGER, his wife, parties of the second part, as tenants key the entireties, Grantees WITNESSETH, that in consideration of Forty-one 'thousand Five Hundred------ --------------------Dollars, ($41,500.00)----------------------------- in hand paid, the receipt whereof is hereby acknowledged, thE; said grantor does hereby grant and convey to the said grantees ,their- heirs and a s ,~ i g n s , ALL That certain lot or piece of land situated in Lower Allen Township, Cumberland County, Pennsylvania, bounded and described as follows: BEGINNING at an iron pin, said pin being one thousand ninety- five (1095) feet from the northeast corner of Thirty-second Street and Morningside Drive; thence eastwardly along the northern side of Morningside Drive sixty (60) feet to an iron pin; thence northwardly along the line of property of Paul L. Cressman, Jr. and Thelma M. Cressman, his wife, and others, one hundred fifty (150) feet to an iron pin; thence westwardly along the l.in.e of property of the Pennsylvania Railroad, sixty (60) .feet to an iron pin; thence south- wardly along the line of property of Pawl. L. Cressman, Jr. and Thelma M. Cressman, his wife, and other's, one hundred fifty (150) feet to an iron pin, the place of Beginning. BEING the same premises which P~~u:L L. Cressman, Jr. and Thelma M. Cressman, his wife, .Earl N. Stauffer and Hazel C. Stauffer, his wife, and Lawrence F. McVitty and Claire C. McVitty, his wife, by deed dated April 7, 1954, recorded in ~thf: Cumberland County Recorder's Office in Deed Book S, Vol. 15, Page 73, granted and conveyed unto William H. Graham and Thelma G. Graham, ]pis wife. The said William H. Graham having died the 22nd day of April 1968, title remains vested in Thelma G. Graham as surviving tenant by the entireties. HAVING THEREON ERECTED a one story brick dwelling house known as 2910 Morningside Drive, Camp Hill. ~ ~.. Township oK ..................:: Cumb. Co., Pa. '(°/ Real Estata Trans~er Tax ~, ~ ~~~ •n / Date :........... A ..., ... "=-- ~umb. Co. Dist. Col. Agt./~ l School Dist. Cumil, Co-. Pa. Rea{ Estate Transfer Tax Date y. d Amt. / j ..rte?` '~,,,.,h. Co. Dist. Col. A9~ ~.~~~ - ~~ r<<,cE 3b~. And the said grantor hereby covenants and agree =~ t'~t the property hereby conveyed. 2uill warrant genera 11 y `~' COMMONiVJE;A~.Tt ~ O~ ~Er!N~', ~-~,~.r';~. =_ pEP~:RTMENT OF REVENI}F _ _ w ~-- -~- ~ x ~ Ti2AfvSFER a~< f~ ° ~ ~k ~ ~ ~1 :. P.B.I t tG2 __..n.._.~.-.. 0 IN WITNESS WHEREOF, said grantor has hereunto set her hand and seal the day and year first above written. n , ~~~ FJ ~ l A .~~y~ ~ " AL , ,f I'y~ ~ ~~ -,~'`N` rf~. !/a.- !' /.('~ ~ SE ~i~tnr~, ~,ealyd aYCa ~eliurrr~ Tri tI~P ~TPSY1ttP Df The 1 ma G . Graham ~4,1^1~~ J -~ G !------------- ~ ------°" SEAL :---'-~ ~ BY'"'-~~~ ~ Critchle Irene G. F a c t ney i n t ~..~ _---. SEAL or At "~/`,'~~r. L-i~.~_____---- L9f151 F!~ fu ~'~ B h -------- sEAr. --------------___ ------------------------------- , i _ - y.~- -- _-____- ---- t; . Rat The 1 m a Attorneys-in -Fact State of Pennsylvania ss. County o f Cumberland ~ day of ~ J~r~~ ~ Ig 7 8 ,before me, On this, the .3 a eared Irene (~. Critchley and Thelma G. the undersigned o ffieer, personally app Graham Rathfon, Attorneys-in-Fact for Thelma G.. known to me (or satisfactorily proven) to be the persons whose names are subscribed to th~ ~ executed same ~~~'~~~ within instrument, and acknowledged that they ur oses therein contained.~<~ as the act of their principal for the p p ,~ ~~~a$~aed. ~ ~~ , IN WITNESS WHEREOF, I hereunto set my ha~r~d and official seal. ~+Q~.. ~ ~ ,.~1 N. -- 1~J :--- gEAL ~ >:rl` `/''~' ------- -- ~ w 4 •: ~~TARY P r ` ~~' 1~ ~. ~ 4 f 1 ~~~.~ ~'~1 --~'t"~~'lgland Coont~ r O cG?" ~. , Y Lemo,~ttS, Fa. 'l 2t16 Af ~' f.~ ,. . ~,~~,,.. State of ss. Gounty o f day o f , 19 ,before me, On this, the the undersigned officer, personally appeared subscribed to the known to me (or satisfactorily proven) to be the person whose name executed same for the purposes therein within instrument, and acknowledged that contained. IN WITNESS WHEREOF, I hereunto set my hand and official sea . ~~ --------------------- sEAL - - -- ---- - - -- -- - ------------------------- ------------~----------- Title of Officer. '~`-' do hereby certify that the precise residence and~ost office Tess /~ o f the within named grantee is ~-i / o ~ac.,~'Z.r-~--~--"-~S'~~ ~~' ~~~ ~ ~ ~f</ ----- ----------------- - --------------------------------------------- At~tor7iey for -------- ------- EO~~ ~~ F;~E ~~;~ ------------~::,~,;;z~;M ----------- •ua~~?.~n2 aaogn a~np a~~ o p?ns a~y~ ~o Ina pun punz~ Luc .~apun ua~t?~ -- aBnd ~-----~--~-------- •20~ r / (J Moog paaQ u? `~i~uno,~ p?ns a~~ ~o aa~o s~.cap.~oaad a~~ uz ~6I 'Q 'b' ~- - - - - - - ----------------------- ~o ~~p ------,-- - -------------- s?~~ uo Q'~Q210~'Q~I ~ - - ---------`~--x o 0 •ss y'I1~iT~4.7dS1~It~IQd ,~O H ~ ~'~d~il~l ZtTOa x x x r ~ ~n~ r ~~ ~~ ~~~~ ~ '~ A ~ x x ~ ~ ~ L~ ~ O '^ ~ ~ ~ p H y G7 ~ a ~ ~~` ~ i n r t G7 rt ~ ~ c N ~ ~~ ~ ~no~ Ci' f'r '.'3 y ~b O o ~ 1~ ~C ~, ~ r- f..~ a w - ~- ~- ono ~ ~ . ~o rt Z 137 ro t~ Q~ G Rev-1508 ex+ (6-98i gC H E D U LE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Shotsberger, Hilda M. FILE NUMBER 21-10-0559 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on schedule F. (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-Oi= ) Wells Fargo Advisors, LLC Te1717-761-7344 ~.. ~~'' ~ ; Three Lemoyne Drive Fax 717-975-8426 800-468-8685 . * ~ ~ ~ ~'~ ~~ . Lemoyne, PA 17043 ,~ ~~`~ August 19, 2010 James D. Bogar Attorney At Law One West Main Street Shiremanstown, PA 17011 RE: Estate of Hilda M. Shotsberger Dear James, We are responding to your letter requesting information for the estate of Hilda M. Shotsberger. Ms. Shotsberger had one account with us. That account was solely owned. The value of the account on the date of death, May 11, 2010, was $124,251.54. Please see the attached spreadsheet for a breakdown by individual security. As discussed earlier, Russell has retired, so please feel free to contact me directly with any more questions. Sincerely, Michael C. McConahy, CRPC® Financial Advisor Member FINRA/SIPC C -I -I -I -~ -I -I C~ (/) ~ ~ ~ ~ '~ "~ '~ O Z Z ~ ~ r r r ~ T O z G~ rn rn O ~ ~ ~ C7 C7 D D D D C7 OOm~~ .~Dzr-~OmmOT<-~~~ o _z~Ommmrn--iDOmmzz'!~m<O'o~C~ z ~ m cr-OQ° ~ ~ rrmD~ -<~~ N~moo-vv~ ~C) D-n m~cn!r' ~°°--~Ozz--~~~-~ <~~~cm~-~myz~n Dm~~rOc~~~z-nzDO~.~rm Ocnyo z ~ mOOrcnc) O~rpOmn~C~mmzoo~~m~~Dm~z:D ~m=rpn-~~ D ~ ~cnymn0-<~_~rr'~r ODn-~v~O~m OZr ~m_=G) ~ O~c~ ooh rn cn0 c~ nmcn ~zmm-~ cn Dm~z Dz O m=-npo00- G7 ~ ~ ~ ~ ~ r - -1 C7 m C7 -i ~ - W r'm-~r~-i~y~ny~c~ =-~mc ~~o~Oz 'fin mDm m O~~z ~~ ~D~ n~ -v pop` ~~ ~~ r' mr~~-~ ~~ O y O ~ ~~ r=-DD =~ ~O T.p C7 rn ~ r r r~ T- -i ~ rn r O ~ 0 0 n n D -~ D D v~ c-i--i-~--i~-~cncn~~~-o-v-v-oOzz~~ m-noo~m ~-~Ooo--ir-n< ooc~ z~-c ~-ID-<Drnzz~mcnm~-ICnO~ ~ ~~ z OT, _-~~~r,-, -o0 -IC~ -.~z-I DG~z ~m~o ~° pro -~ - ao ~ N11CO.A-W .A• CONW N W W W~ 00 W NNE W A N N N W~ N -~ C11 W O E ~ N ~ O 00 ~ O Cr 00 .A O N U~ W N -~ O W E N O O -P O W N -~ CJ~ N O 00 COO O~~ CTS ~I W~ j ~ W~~ O~ ~ O W W O CJ~ ~~O~Cn11:~DDO~CO~I~cOCrO~O~.ACn11~ OOO.p Cr ~NN~oo-~ W CA 00 DD O CO DD ~ W O N CO O O (Ti (n O N O W GJ O CO W CD N N O -~ CO ~ ~ ~ IV ~ CJi CO 00 CO O O O W ~ ~, ~ W O ~ W .p O .p CO .A C11 ~ O CO O O U1 W CO ~l N .A, ~ 11 CJt • 11 CO ~ N ~ ~ ~ t~D ~ ~. W -~ O ~ W N N O W ~ W J~ -~ ~ W ~ W ~ N W ~ N ~ OND UNi CNO CAD ~ O CJ~ ~ ~l N W~ N N W (n ~~ W Cr O O W O O C37 O O W O O .A O OD J~ --~ (n ~ 11 O ~ W ~ -a O GJ .A N ~1 00 1~ ~ A W ~ Cn C3't -~ Oo N ~l OD ~ W OD O ~ O N CJ1 (~ .~. ~I O CJt W W N O DD O -'' Op, ~ ~ ~ COO cWp W U~i~A ~ 000 --~ .P O O CJ~ CJi CJi A N W O O O ~ W OD ~! ~I N 00 N O CO ~I W ~l CO ~- COO (D O .~ -~ N N N W N -' -~ ~ .~ ~ ~ W N N W N ~ ~ CO CO N O ~ W ~ -~ .A ~ ~ -p CO ~l -~ U1 W 11 W C~ W N W CO N -~ C,:r O ~ 00 W .A CJ1 O W OD ~i CJ'i CO O ~ .A W cD ~ CO ~ W W O DD O N 11 W CJ7 07 O W O ~ O ~ (17 O OD CO' ~ W ~ W ~ C10i N ~ O ~ O ~ ~ ~ Cl~ ~ ~A N ~ W O CJ~ O ~ OD W W -~ N CO Cr NOD O OD CJ1 00 11 .p CO CJi CL~ _, ~p CO IV N (3i CJi ~I -~ N O O N N W W (n ~ 0 0~ O~ CJi CTi -~ W (37 OD -~ -~ O W W ~I N O O W O -p Q 11 CO 11 CJi O -~ ~ O A NOD N 0) ~l ~I CO Cn CO ~ Cn ~! O .p CO CO O OD O OD Q- .p .A A CJi N W W N 0) ~ O ~p rt rr iU ~ n ~_ ~ ~_ C fn (D ~ 3 ~ ~ ~ ~ ~ N N ~ W N W OD ~.a ~ ~ t!7 ~l 00 .p -~ W Rev-1509 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF FILE NUMBER Shotsber er, Hilda M. 21-10-0559 A. James A. Shotzberger B. C. 3443 Broodridge Drive Son Mechanicsburg, PA 17050 JOINTLY OWNED PROPERTY: ITEM NUMBER LETTER FOR JOIN 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 ASSE % OF ~ DECD S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1 A Sovereign Bank -The is a joint account with 489.10 50.000% 244.55 James A. Shotsberger -date of death balance is $489.09; accrued interest $0.01. ff 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 TOTAL (Also enter on Line 6, Recapitulation) I 244.55 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule F (Rev. 6-9~) I • Sovereign Court Ordered Processing \ Decedents - MA 1-MB3-02-10 - P. O. Box 841005 -Boston, MA uLLU4 June 9, 2010 James D. Bogar Attorney at Law One West Main Street Shiremanstown, PA 17011 RE: Estate of Hilda M. Shotsberger Date of Death: 05/11 /10 Dear James D. Bogar: Per your request, enclosed please find the account information as of the date of death for the above-named decedent. For your information, accrued interest is not included in the date of death balance. Please feel free to contact me if I can be of any further assistance. Very truly yours, " ~ 'l.~L ~c ~ j -~{.~--1 1.~.~[i~.' I 'fir L(~'- '~'L i.. C~_-~:./ ~Giandomen~'Co Laurie Di Team Manager 617-533-1789 `u '9 G C O U C LL O 9 L ~p 3 O T O 2 3 ~L C Cq C m "u 0 Sovereign Bank STATE OF Hilda M. Shotsberger SOCIAL SECURITY #: 196-14-3221 DATE OF DEATH: May 11, 2010 Account #: 1051074304 Type: Checking Open date: 11/30/1998 In the name of: Hilda M. Shotsberger or James A. Shotsberger Date of Death Balance: $489.09 Int.(YTD) from 1/1/2010 to 4/6/2010 $0.61 Accrued interest to date of death: $0.01 Other Info: fed tax withheld $.16 Account #: 0461143690 Type: Checking Open date: 6/24/2008 In the name of: Hilda M. Shotsberger Date of Death Balance: Closed prior to n/a Int.(YTD) from Accrued interest to date of death: n/a Other Info: Closed 7/2/08 $100.00 Page 1 of 1 REV-1151 EX+ (10-06) SCHEDULE H FUNERAL EXPENSES & ESTATE OF FILE NUMBER Shotsber er, Hilda M. 21-10-0559 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT A, FUNERAL EXPENSES: See continuation schedule(s) attached I 9,325.96 B. 1. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zia Year(sl Commission paid 2. Attorney's Fees Bogar & Hipp Law Offices 21,000.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zio Relationship of Claimant to Decedent 4. Probate Fees 417.50 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 6,136.28 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 36,879.74 Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-0!?} SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Shotsber er, Hilda M. 21-10-0559 ITEM DESCRIPTION AMOUNT NUMBER Funeral Exeenses 1 Neill Funeral Home -funeral bill 9,325.96 H-A 9,325.96 2 Other Administrative Costs Ameriscape -Lawn maintenance 60.00 3 Bonnie K. Miller, Treasurer -Tax certification fee 10.00 4 Bonnie K. Miller, Treasurer - County/Township Taxes 645.73 5 Bonnie K. Miller, Treasurer -School Taxes 1,195.91 6 Cumberland Law Journal -Legal Advertising 75.00 7 Journal Publications -Legal Advertising 150.00 8 Lower Allen Township -Sewer and Trash bill 600.20 9 PA American Water -Utility bill 256.65 10 PPL -Utility bill 388.69 11 R.T. Dunn -Homeowner's insurance payment 609.10 12 RESERVES: -Costs to conclude administration of Estate including filing fees for PA 2,000.00 Inheritance Tax Return and Inventory, preparation and filing of final Personal Income Tax Returns and Fiduciary Income Tax Returns 13 Sovereign Bank -fee for date of death valuation letter 20.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-~~~~ SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Shotsber er, Hilda M. 21-10-0559 ITEM DESCRIPTION AMOUNT NUMBER 14 Wells Fargo Advisors - 2010 Annual Fee 125.00 H-B7 6,136.28 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-~;) SCH EDU LE H B. 2. EXPLANATION OF ATTORNEY'S FEES ESTATE OF FILE NUMBER Shotsberger, Hilda M. 21-10-0559 DESCRIPTION The attorney's fees generated with respect to the administration of this Estate are in access of attorney's fees which would normally be incurred. The increased number of hours is due to, among other things, extraordinary efforts required as a result of the last illness and untimely passing of ]ames A. Shotsberger on March 23, 2011. Mr. Shotsberger was the originally appointed Executor pursuant to the Last Will and Testament of Hilda M. Shotsberger. As a result of Mr. Shotsberger's untimely passing, additional efforts were required with respect to securing the appointment of Mary E. Shotsberger as Executrix. This matter was further complicated due to the fact that James A. Shotsberger and Mary E. Shotsberger became divorced on October 19, 2010. In addition, difficulties have been encountered with respect to disposition of the real estate, which difficulties are continuing and ongoing. The home located on the real estate became damaged as a result of storms occurring in the Spring of 2011. Additional efforts have been required as a result of the failure of the Decedent, Hilda M. Shotsberger, to file final Personal Income Returns, as well as previously filed Personal Income Tax Returns that were improperly prepared. These efforts are expected to be continuing and ongoing until same are resolved. Finally, additional efforts were required as to a review of the records of the Decedent with respect to determining the existence of additional assets, and, more importantly, the existence of debts and expenses. The agreed upon hourly rate for professional services rendered with respect to conclusion of the administration this Estate is $210.00 per hour, all by agreement with Mary E. Shotsberger, Executrix. A copy of the engagement letter, same being dated April 11, 2011, and further, being acknowledged being acknowledged by Mary E. Shotsberger, Executrix, on April 11, 2011, is attached hereto and made a part hereof. TAMES D. BOGAR ATTORNEY AT LAW ONE WEST MAIN STREET SHIREMANSTOWN,PENNSYLVANIA 17011 www.bogarandhipplaw. com e-mail mail@bogarlaw.com JAMES D. BOGAR JENNIFER B. HIPP* LAUREN E. BOGAR *Also admitted to New Jersey Bar Mary E. Shotsberger 3943 Brookridge Drive Mechanicsburg, PA 17050 April 11, 2011 TELEPHONE (717) 737-8761 FACSIMILE (717) 737-2086 Direct a-mail jbogarQbogarlaw.com RE: The Estate of Hilda M. Shotsberger Dear Mary: We are writing to confirm our recent conversations concerning the Estate of Hilda M. Shotsberger (hereinafter the "Estate") You asked that we provide representation for the Estate. We accept and appreciate your confidence. As we explained, the administration of the Estate will involve many things. Initially, all assets must be identified and valued as of the date of Hilda's death. Efforts are being made to make these determinations. The extent of our representation will include, but not necessarily be limited to, the following: the determination and valuation of assets, the determination and payment of any and all lawful expenses; the filing of all required inheritance tax returns, including the Pennsylvania inheritance tax return and related filing requirements; preparation of accounting, be it a court accounting or an informal or family accounting; any and all miscellaneous correspondence and telephone calls; disposition of assets if required or requested; and various other miscellaneous matters that will present themselves during the course of administration of the Estate. We advised that our fee for legal services to be provided with respect to the administration of the Estate will be based on the total number of hours that we expend to conclude the administration of the Estate. Our hourly rate is $210.00 per hour. This will include professional services rendered by Jennifer B. Hipp, Esquire, Lauren E. Bogor, Esquire and me. Mary E. Shotsberger April 11, 2011 Page 2 Although we are unable to provide you with an estimate at this time as to the number of hours we will be required to expend regarding the administration of this Estate, we can assure you that we will work diligently and quickly. As to payment of fees, we ask that two-thirds (2/3) of the fee be paid at the time that the Pennsylvania Inheritance Tax Return is filed, with the balance being due at the time of preparation of the accounting of the Estate or the conclusion of the Estate. As you are aware, we have accumulated a substantial amount of time to date concerning the administration of this Estate. That time will also be included. Should the need arise for the rendering of extraordinary services, we will reserve the right to make additional charges for services that are so rendered. This would include, but not necessarily be limited to, litigation that may arise during the course of the administration of the Estate. As we explained, it is not normal that extraordinary matters are encountered. We will receive your authority to proceed in these areas. It might also be necessary for me to advance or expend costs on behalf of the Estate. We will keep track of these costs and expenses so advanced. We ask that you countersign a copy of this letter and return same to me in the enclosed self-addressed, stamped envelope. We will endeavor to keep you apprised of all developments in the course of the administration of the Estate. Please feel free to contact me directly at any time if you have any questions. V y truly yours, A~ ~ ~~ AMES D. O AR JDB/bbl DATE: Mary E. Shotsbe e ~~ ~~ Rev-1512 EX+ (12-08) SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Shotsber er, Hilda M. 21-10-0559 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Golden Living Center Claim -See attached claim. 4,753.54 2 IRS - 2005 Personal Income Tax payment 440.00 3 IRS - 2006 Personal Income Tax payment 1,501.00 4 IRS - 2007 Personal Income Tax payment 1,766.00 5 Pennsylvania Department of Public Welfare -Claim for restitution of medical assistance per 22,387.99 attached letter TOTAL (Also enter on Line 10, Recapitulation) I 30,848.53 (If more space is needed, additional pages of the same size) Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 12-Or'?) g<>Iden living Claim Against Decedent's Estate ESTATE OF: Hilda Shotsberger Case# 21-10-05 59 The undersigned hereby presents for filing against the above estate this statement of claim and alleges: Golden Livingcenter- WEST SHORE PITTSBURGH LLC PO BOX 180970 Fort Smith, AR. 72918-0970 The basis of claim is: SEE ATTACHED: The amount of the claim is $4753.54 NOTE- If there is insurance pending on this account and the insurance fails to pay then amount will become due privately Under penalties of perjury, I declare that I have read the foregoing, and the facts alleged are true to the best of my knowledge and belief. Signed ON: September 29, 2010 n Tankersley, ollections Manage I SWEAR THIS STATEMENT IS CORRECT Subscribed and sworn to before me On + ~ dt Notary Pubi' 1 My C~mmissi~n ExNires P.o. Box 180970 Fort Smith, AR 72918 Phone: 479-201-2000 Toll-Free: 877-823-8375 www.goldenliving.com .~ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF PROGRAM INTEGRITY DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG, PA 17105-8486 June 10, 2010 JAMES D BOGAR ATTORNEY AT LAW ONE WEST MAIN ST SHIREMANSTOWN PA 17011 Re: Hilda Shotsberger CIS #: 740246820 SSN: ###-##-3221 Date of Death: 05/11/2010 Dear Attorney: Please be advised that the Department of Public Welfare maintains a claim in the amount of $22,387.99 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 $22,387.99, 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 $.00, is to be entered as a priority Class 5.1 claim against the estate. Please acknowledge receipt of this letter and advise whether the Commonwealth's claim is admitted and when payment may be expected. If the estate accounting is complete, please provide a copy. If the estate contains real estate, please provide copies of the deed, the latest tax assessment, and a current appraisal, if available. Sincerely, fir.- '~', Patricia Nace Claims Investigation Agent 717-772-6616 717-772-6553 FAX Enclosure "' , COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS TPL SECTION -CASUALTY UNIT PO BOX 8486 HARRISBURG PA 17105-8486 June 9, 2010 STATEMENT OF CLAIM SUMMARY NAME' Estate of SHOTSBERGER, HILDA I D 740 246 820 MEDICAL CLASS 3 CLASS'5.1 TOTAL INPATIENT .00 .00 .00 OUTPATIENT .00 .00 .00 LONG TERM CARE 22,387.99 .00 22,387.99 DRUG .00 .00 .00 .REIMBURSEMENT TO DPW 22,387.99 .00 22,387.99 COMMQNWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE: EIN - 23=60031.13 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE June 9, 2010 STATEMENT OF CLAIM NAME SHOTSBERGER, HILDA 10 740 246 820 GOLDEN LIVINGCENTER-WEST SHORE 770 POPLAR CHURCH RD :AMP HILL PA 17011 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 12/02/09 - 12/31/09 05/25/10 27101454020140001 27101454020140001 2,829.45 1,373.49 DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP DIAGNOSIS 2 : 5990 URIN TRACT INFECTION NOS PROC CODE : 000000 01/01/10 - 01/31/10 05/25/10 27101454020170001 27101454020170001 6,747.15 5,291.19 DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP DIAGNOSIS 2 : 5990 URIN TRACT INFECTION NOS PROC CODE : 000000 02/01/10 - 02/28/10 05/25/10 27101454020180001 27101454020180001 6,094.20 4,638.24 DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP DIAGNOSIS 2 : 5990 URIN TRACT INFECTION NOS PROC CODE : 000000 03/01/10 - 03/31/10 05/25/10 27101454020200001 27101454020200001 6,747.15 5,291.19 DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP DIAGNOSIS 2 : 5990 URIN TRACT INFECTION NOS PROC CODE : 000000 04/01/10 - 04/30/10 05/25/10 27101454020210001 27101454020210001 6,529.50 5,073.54 DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP DIAGNOSIS 2 : 5990 URiN T RAc;T INFECTION WOS PROC CODE : 000000 05/01/10 - 05/11/10 05/25/10 27101454020230001 27101454020230001 2,176.50 720.34 DIAGNOSIS 1 : 2900 SENILE DEMENTIA UNCOMP DIAGNOSIS 2 : 5990 URIN TRACT INFECTION NOS PROC CODE : 000000 PROVIDER SUB TOTAL GOLDEN LIVINGCENTER-WEST SHORE 31,123.95 22,387.99 03 101553152 0001 REV-1513 EX+ (11-08) SCHEDULE J COMMNHERITAN ETF,a~PCRENSURNANIA BENEFICIARIES RESIDEN~ DECEDENT ESTATE OF FILE NUMBER sno><sper er, niiaa m. I c~--iu-ua aa NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(Sl RECEIVING PROPERTY DECEDENT (Words) ($$$) I TAXABLE DISTRIBUTIONS [include outright spousal • .distributions, and transfers under Sec. 9116 a 1.2 1 James A. Shotsberger Son Rest, residue Deceased - 3/23/11 and remainder of Subsequent to the death of Hilda M. Shotsberge Estate Total Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 150 0 cover sheet, as a r o riate. NON-TAXABLE DISTRIBUTIONS: II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEETI ~:~~ Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-0~; LAST WILL AND TESTAMENT OF HILDA M. SHOTSBERGER r~ .~~~- ~, r ~,. ~~~ ~~ ,; . ~;~ I, HILDA M. SHOTSBERGER, of Lower Allen Township, Cumberland County, Pennsylvania, make, publish and declare this as and for my Last Will and Testament, hereby revoking all other Wills and Codicils heretofore made by me. FIRST: I devise and bequeath all the rest, residue and remainder of my estate of whatever nature and wherever situate, including any property over which I hold power of appointment and together with any insurance policies thereon, to my son, JAMES A. SHOTSBERGER. SECOND: Should my son, JAMES A. SHOTSBERGER, prede- cease me, then I devise and bequeath all the rest, residue and remainder of my estate of whatever nature and wherever situate, including any property over which I hold power of appointment and together with any insurance policies thereon, to his wife, MARY E. SHOTSBERGER. THIRD: In addition to all powers granted to them by law and by other provisions of this Will, I give the fiduciaries acting hereunder the following powers, applicable to all proper- ty, exercisable without court approval and effective until actual distribution of all property: (A) To sell at public or private sale, or to lease, for any period of time, any real or personal property and to give options for sales, exchanges or leases, for such prices and upon such terms (including credit, with or without security) or conditions as are deemed proper. This includes the power to give legally sufficient instruments for transfer of the property and to receive the proceeds of any disposition of it. (B) To partition, subdivide, or improve real estate and to enter into agreements concerning the partition, subdivi- sion, improvement, zoning or management of real estate and to impose or extinguish restrictions on real estate. (C) To compromise any claim or controversy and to abandon any property which is of little or no value. (D) To invest in all forms of property, including stocks, common trust funds and mortgage investment funds, without restriction to investments authorized for Pennsylvania fiduci- aries, as are deemed proper, without regard to any principle of diversification, risk or productivity. (E) To exercise any option, right or privilege granted in insurance policies or in other investments. (F) To exercise any election or privilege given by the Federal and other tax laws, including, but not necessarily being limited to, personal income, gift and estate or inheritance tax laws. (G) To make distributions to my herein named benefici- aries in cash or in kind or partly in each. (H) To borrow money from themselves or others in order to pay debts, taxes, or estate or trust administration expenses, to protect or improve any property held under my will, and for ~ investment purposes. (I) To select a mode of payment under any qualified ~! retirement plan (pension plan, profit sharing plan, employee stock ownership plan, or any other type of qualified plan) to the extent the plan or the law permits them to do so, and to exercise any other rights which they may have under the plan, in whatever ~ manner they consider advisable. FOURTH: I direct that all inheritance, estate, trans- ~; ~ fer, succession and death taxes, of any kind whatsoever, which J may be payable by reason of my death, whether or not with respect to property passing under this Will, shall be paid out of the principal of my residuary estate. FIFTH: All interests hereunder, whether principal or income, which are undistributed and in the possession of the fiduciaries acting hereunder, even though vested or distribut- 2 J able, shall not be subject to attachment, execution or sequestra- tion for any debt, contract, obligation or liability of any beneficiary, and furthermore, shall not be subject to pledge, assignment, conveyance or anticipation. SIXTH: I nominate and appoint JAMES A. SHOTSBERGER, Executor of this, my Last Will and Testament. In the event of the death, resignation or inability to serve for any reason whatsoever of the said JAMES A. SHOTSBERGER, I nominate and appoint MARY E. SHOTSBERGER, Executrix of this, my Last Will and Testament. I direct that my Executor or Executrix, as the case may be, and their successors, shall not be required to post security or a bond for the performance of their duties in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will and Testament, thisr~ ~~" day of ~~~~ 1997. i'~~tiG~- ~JyI mod/ SEAL) HILDA M. SHOTSBERGER Signed, sealed, published and declared by the above- named Testatrix as and for her Last Will and Testament in our presence, who, at her request, in her presence and in the presence of each other, ha~~e hereunto subscribed our names as ~;~ attesting witnesses. Address Address t_~r~....d~. ~ .~....~: •, ~, 3