HomeMy WebLinkAbout08-05-11 1505610101
REV-1500 Ex t01 -'°' ~1
PA Department of Revenue OFFICIAL USE ONL.X
Pennsylvania ---- -
Bureau of Individual Taxes "EPA"'"`"~ ` `°`"°` County Code Year File Number
"INHERITANCE TAX RETURN
PO Boxz8o6o1
Harrisburg, PA i~128-o6oi RESIDENT DECEDENT 2 I 1 :l 0 0 1 3 7
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
1 9 5 1 6 2,8 1 9 0 1 2 7 2 0 1 1' 0 6 3 0 1 9 2 4,
Decedent's Last Name Suffix Decedent's First Name MI
D E T W E I 'L E R CH A R L E S E
(If Applicable) Enter Surviving Spouse's Information Below
Spouse'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 O 2. Supplemental Return O 3. Remainder I~eturn (date of death
prior to 12-13-82)
O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required
death after 12-12-82)
~ 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 1 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to t~3x 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 T0:
Name Daytime TelephonE~ Number
M a r 1 i?.n R Mc C a 1 e b 7 1 7 6 9'1 7 7 7 0
First line of address
2 1 9 E a s t M' a i ?n S t r e e t
Second line of address
P O B o g 2 3 0
City or Post Office State ZIP Code
M e c h a n i c s b u r g P A 1 7
Correspondent's a-mail address:
----
REGIST ~VILI_S US)F:_'ONLY _ .
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~~C,1"E FILED __.-
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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 prepares other than the personal representative is based on all information of which prepares has any knowledge.
SIGNATURE OF PERSON RES~§1NS1BUE b9R~FILING RETURN ~~ r1ATL
ADDRESS
Ip sen
Side 1
1505610101
1505610101
27 9 East M ~*+ Street_ Mechanicsbi~'g, PA 170 _
P Eg SE USE ORIGINAL FORM ONLY~~~_-- -_-'- '-4
J
REV-1500 EX
1505610105
Decedent's Name: Ch21x'1eS E. Detweiler
RECAPITULATION ~ s
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 and Notes Receivable (Schedule D) ........................... 4.
Decedent's Social ~~ecurity Number
1 9 5 1 6 2 8 1 9-
0 •0 0
0 ,0 0
0 .0 0
0 •0 0
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. 6 9 1. 1 2 • 3 5
6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested ..... .. 6. 0 • 0 0
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested...... .. 7. 5 5 4 4 1` 7 2
8. Total Gross Assets (total Lines 1 through 7) ........................... .. 8. 1 2 4 5 5 4 • 0 7
9.
P ( ) .................
Funeral Ex enses and Administrative Costs Schedule H
..
9. 1 8 :S 1 1 , 9 3
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............ .. 10. 4 2 0 5 • 5 2
11. Total Deductions (total Lines 9 and 10) ............................... .. 11. 2 2 5 1 7' 4 5
12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. 1 0 2 0 3 6 , 6 2
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ...................... .. 13.
14. Net Value Subject to Tax (Line 12 minus Line 13) ...................... .. 14. 1 0 2 0 3 6 , 6 2
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .00 .
15.
0 ~ 0
0
16. Amount of Line 14 taxable
at lineal rate X .0 4~ 0, 0 0 16. 0 0 0
17.
Amount of Line 14 taxable ,.
at sibling rate X .12 0~ 0 0 17. 0 ~~ 0 0
18. Amount of Line 14 taxable 1
0 2 0 3 6. 6 2 1 5 3 0 -~
5 9
.
at collateral rate X .15 1 g. •
1~ .5 ~ : 0 ~~..R; ~ ~~~:
19. TAX DUE ....................................................... ..19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p
Side 2
1505610105 150561D1D~i
REV-1500 EX Page 3 File Number
Deceden't's CoMplete Address: 21 - 2011 - 0137
Charles E. Detweiler
--
STREET ADDRESS
100 Mount Allen Drive
CITY
Mechanicsburg
STATE
PA
ZIP
17055
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments ___
B. Discount
3. Interest
7,500.00
394.74
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.
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
(1) 15,305.49
Total Credits (A + B) (2) _ 7,894.74
(3) 0.00
(4) 0.00
(5) 7,410.75
Make check payable to: REGISTER OF WILLS, AGENT.
~ _ ~~ -
~;'~,~~<5~'~ .~~i{!'p X7.'4= ~~'~~ n¢x~c ,~ry~ ~~~ ~, t `
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 Dec. 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ........................................................................................................ ...... ~ ^
3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? ........ ...... ^
4. Did decedent own an individual retirement account, annuity or other non-probate property, which
contains a beneficiary designation? .................................................................................................................. ...... ® ^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is
3 percent [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
(72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an
adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a}(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in
72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)('1,3;1]. 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-t~08 EX . (1-~7)
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, ~ MISC.
IN RESIDENTDE~ DEN RN PERSONAL PROPERTY
ESTATE OF FILE NUMBER
Charles E. Detweiler SS~~ 195-16-2819 01/27/2011 _?1-2011-0137
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of
survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 PNC Bank, - Checking Account ~~5070079298; principal balance as oi: 53,732.95
D.O.D.: $53,731.55; interest accrued to D.O.D.: $1.40.
2 Banker's Life and Casualty Co., - reimbursement for December 1,240.00
medical care expenses at Messiah Village.
3 Bankers Life and Casualty Co., - reimbursement for January 1,040.00
medical care expenses at Messiah Village.
4 Commonwealth of Pennsylvania, - refund of Medicare Part B 135.10
penalty.
5 Neil Funeral Home/AML Insurance Co., - pre-need funeral contract, 9,711.00
purchased 01/20/2011.
6 PNC Bank, - refund of safe deposit box rental. 22.00
7 Romberger Memorials, - pre-need gravemarker purchase (purchased 2,932.00
01/25/2011).
8 State Employees' Retirement System, - direct deposit of 298.13
retirement annuity.
9 U. S. Treasury, - refund of 2010 federal tax withholding. 1.17
TOTAL (Also enter on line 5, Recapitulation) 1$ 69 ,112.35
(If more space is needed, insert additional sheets of the same size)
Copy rig ht (c) 1496 form software onlyCPSystems,Inc. Form REV-t5~8 EX (Rev. 7-97)
REV-1510 EX +(1-9'7)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
SCHEDULE G
INTER-VIVOS TRANSFERS 8~
MISC. NON-PROBATE PROPERTY
ESTATE OF FILE NUMBER
Charles E. Detweiler SS~~ 195-16-2819 01/27/2011 21-2011-0137
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes.
ITEM
NUMBER DESCRIPTION OF PROPERTY
RELATIONSHIP TO DECEDENT AND THE DATE O~ TRANSFER.
ATTACHACOPYOFTHEDEEDFORREALESTATE.
DATE OF DEATH
VALUE OF ASSET % OF
DECD'S
INTEREST
EXCLUSION
(IF APPLICABLE)
TAXABLE VALUE
1 MorganStanleySmithBarney, - 44,333.12 44,333.12
Account ~~213-37999-12, in
name of Decedent, TOD Amily
Ann Russ; principal balance
as of D.O.D.:
2 Emily Burbage Russ Ipsen, - 13,000.00 100.00% 3,000.0() 10,000.00
cash gift from decedent on
01/17/2011.
3 Emily Burbage Russ Ipsen, - 1,108.60 1,108.60
gift of furniture when
house was sold on
06/29/2010 (straight-back
chair, loveseat, lamp).
TOTAL (Also enter on line 7, Reca
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc.
55,441.72
Forrn REV-1510 EX (Rev. 1-97)
REV-1511 EX + (1-97)
SCHEDULE H
FUNERAL EXPENSES 8~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Charles E. Detweiler SS~~ 195-16-2819 01/27/2011 21-2011-0137
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1 Neil Funeral Home, - funeral expense. 10,041.12
2 Romberger Memorials, - gravemarker. 2,932.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s) / EIN Number of Personal Representative(s)
Street Address
City State Zip
Year(s) Commission Paid:
2. Attorney's Fees Law Offices-Marlin R. MCCaleb
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
4.
5.
6.
7.
1
2
3
4
5
Street Address
City State Zip
Relationship of Claimant to Decedent
Probate Fees Register of Wills
Accountant's Fees
Tax Return Preparer's Fees
Other Administrative Costs
Cumberland Law Journal, - advertising Letters.
Register of Wills, - Short Certificate.
Register of Wills, - filing Inventory and Appraisement.
Register of Wills, - reserve for filing Account, Releases, etc
The Patriot-News Co., - advertising Letters.
TOTAL (Also enter on line 9, Reca
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc.
4,600.00
198.50
75.00
5.00
30.00
300.00
130. `_31
1~ 18 , 311.93
Forrn REV-1511 EX (Rev. t-97)
REV-1512 EX +(1-97)
SCHEDULEI
DEBTS OF DECEDENT,
COMMONWEALTH OF PENNSYLVANIA
TN
~N AND LIENS
MORTGAGE LIABILITIES
RESIDENTDECEDEN ,
ESTATE OF FILE NUMBER
Charles E. Detweiler SS~k 195-16-2819 01/27/2011 21-2011-0137
Include unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION AMOUNT
1 Dr. Paul Dalbey, - account payable, medical. 15.00
2 Messiah Village, - account payable, medical care for January. 4,009.13
3 Messiah Village, - account payable, medical (therapy charges for 80.76
January).
4 Pennsylvania Department of Revenue, - account payable, 2010 27.10
personal income tax.
5 Smith Radiology, Inc., - account payable, medical. 8.00
6 State Employees' Retirement System, - pro-rated return of 29.81
January's annuity payment (01/28-01/31/11).
7 Verizon, - account payable, telephone. 35.72
TOTAL (Also enter on line 10, Recapitulation) 1$ 4 , 205.52
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 form software only CPSystems, Inc Form REV-1512 EX (Rev. 1-97)
REV-113 EX + (9-tl0)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
SCHEDULE)
BENEFICIARIES
ESTATE OF FILE NUMBER
Charles E. Detweiler 55~~ 195-16-2819 01/27/2011 21-2011-0137
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I. TAXABLE DISTRIBUTIONS [include outright spousal distributions,and
transfers under Sec. 9116(a)(1.2)]
1 Kevin Stuart Russ Grandnephew 698.92
1111 Post Oak Blvd ~~2302
Houston, TX 77056
2 Ellen Elizabeth Russ Grandniece 698.92
P. 0. Box 1235
Pacific Palisades, CA 90272
3 Ralph and May DeBlasio Friends 698.92
608 South Arlington Ave.
Harrisburg, PA 17101
4 Emily Burbage Russ Ipsen Niece 99,939.86
P. 0. Box 357
Lincolndale, NY 10540
ENTER DOLLAR AMTS. FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 18, AS APPROPRIATE, ON Ft EV 1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ 0.00
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 2000 form software only The Lackner Group, Inc. Form REV-1513 EX (Rev. 9-001
LAST WILL AND TESTAMENT
I, CHARLES E. DETWEILER, of the Township of Hampden, County of
Cumberland and Commonwealth of Pennsylvania, being of sound and disposing
mind, memory and understanding, do make, publish and declare this as and for my
Last Will and Testament, hereby revoking and making void all former wills and
codicils by me at any time heretofore made.
FIRST. I order and direct that my funeral be conducted in a manner
corresponding with my estate and situation in life and that I shall be interred in the
Seabolt Deitzler Plot of the Evergreen Cemetery located in Annville, Pennsylvania,
along with my parents and grandparents. I further order and direct that my funeral
arrangements shall be attended to by the Neill Funeral Home, of Camp Hill,
Pennsylvania. I further order that all my just debts and funeral expenses, including
the costs of placing a grave marker and the sum necessary to arrange for the
perpetual care of my grave, be paid by my Executor or Executrix, as they ease may
be, hereinafter named, as soon as conveniently may be done after my decease.
SECOND. If my niece, EMILY BURBAGE RUSS, survives me, then and in
that event I dispose of my estate as follows:
A. I make the following bequests to be computed on the nei value of
my estate after payment of my funeral expenses, administration costs, debts and
liabilities (but not before payment of estate and inheritance taxes), as follows:
1. I give and bequeath an amount equal to one and one-half (1-
LAW OFFICES
~N K. M~cA~EH 1/2) per centum thereof unto my grandnephew, KEVIN STUART RIJSS,
__ -
presently of Chicago, Illinois, if he survives me;
2. I give and bequeath an amount equal to onE~ and one-half (1-
1/2) per centum thereof unto my grandniece, ELLEN ELIZABETH RUSS,
presently of Chicago, Illinois, if she survives me;
3. I give and bequeath an amount equal to one and one-half (1-
1/2) per centum thereof unto my friends, RALPH DE BLASIO and MAY DE
BLASIO, his wife, or to the survivor of them if either is not thE;n living,
provided that at least one of them survives me;
4. I give and bequeath an amount equal to one ('1) per centum
thereof unto the LAKESIDE LUTHERAN CHURCH, 245 Division Street,
Harrisburg, Pennsylvania, for use in the general fund, in memory of my
parents, Mr. and Mrs. Charles Edgar Detweiler, and my grandparents, The
Rev. Mr. and Mrs. Martin Luther Deitzler;
5. I give and bequeath an amount equal to one (1) per centum
thereof unto my friend, JOHN BOLASH, presently of Hershey, Pennsylvania,
if he survives me.
B. I give, devise and bequeath all the rest, residue and remainder of
my estate, real, personal and mixed, whatsoever and wheresoever situate, unto my
niece, EMILY BURBAGE RUSS, presently of Chicago, Illinois.
THIRD. If, however, my niece, EMILY BURBAGE RUSS, doe; riot survive
me, then and in that event I dispose of my estate as follows:
A. I make the following bequests to be computed on th~a net value of
LAW C)1=FICEti
MARLIN R. McCALE6
-2-
my estate after payment of my funeral expenses, administration costs, debts and
liabilities (but not before payment of estate and inheritance taxes), as follows:
1. I give and bequeath an amount equal to onE~ (1) per centum
thereof unto the LAKESIDE LUTHERAN CHURCH, 245 Divi:~ion Street,
Harrisburg, Pennsylvania, for use in the general fund, in mernory of my
parents, Mr. and Mrs. Charles Edgar Detweiler, and my grandparents, The
Rev. Mr. and Mrs. Martin Luther Deitzler;
2. I give and bequeath an amount equal to onE~ (1) per centum
thereof unto the TRINITY EVANGELICAL LUTHERAN CHUF;GH, 200
Chestnut Street, Camp Hill, Pennsylvania, for use in the general fund;
3. I give and bequeath an amount equal to one and one-half (1-
1/2) per centum unto RALPH DE BLASIO and MAY DE BLASIO, his wife, or
to the survivor of them if either is not then living, provided that at least one of
them survives me.
B. I give, devise and bequeath all the rest, residue ar~d remainder of
my estate, real, personal and mixed, whatsoever and wheresoever situate, in equal
shares unto my grandnephew, KEVIN STUART RUSS, and my grandniece, ELLEN
ELIZABETH RUSS, share and share alike, absolutely and in fee simple; provided,
however, that if either of them shall predecease me, then the share provided
herein for such deceased grandnephew or grandniece, as the case may be, shall
be paid over and distributed to the other grandnephew or grandniece, as the case
may be, who survives me; and provided further, that if both of them shall
LAVV OFFICES
MARLIN R. McCALEB
-3-
predecease me, thenPl give, devise and bequeath the said rest, residue and
remainder of my estate unto their father, SCOTT RUSS, absolutely and in fee
simple, if he survives me.
FOURTH. I direct that each legatee and devisee shall bear thE~ estate,
inheritance and other death taxes, state and federal, attributable to Isis or her
distributive share of my Estate.
LASTLY. I nominate, constitute and appoint my niece, EMILY BURBAGE
ROSS, Executrix of this, my Last Will and Testament, but if for any reason she
shall fail to qualify as such Executrix or cease so to serve, then I nominate,
constitute and appoint my attorney, MARLIN R. McCALEB, to serve in her place
and stead, each to serve without bond in this or any other jurisdiction. In the event
that my niece, EMILY BURBAGE RUSS, shall serve as Executrix under this
paragraph of my Will, I request that she engage the legal services of my attorney,
MARLIN R. McCALEB.
IN WITNESS WHEREOF, I CHARLES E. DETWEILER, have hereunto set my
hand and seal to his, my Last Will and Testament, which consists of~ five (5)
typewritten pages to each of which I have affixed my signature this __~~_ day of
`1~1r: c_~,~.~ , A.D., Two Thousand Five (2005).
~~~ {~~; ~~:~.~ ~ ~,C~ ~~ ~ x ~,~~ (SEAL)
The preceding instrument, consisting of this and four (4) other typewritten
LAVY OFFI(~ES
MARLIN R. McCAI_FB _4_
.. ____~--.______ _ ,~_~. ..-_..n.._.~....__ ......_,_. ~.p.._ ._ _.~__._ _ .
pages, each identified by the signature of the Testator, was on the date thereof
signed, sealed, published and declared by CHARLES E. DETWEILER, the Testator
therein named, as and for his Last Will and Testament, in the presence of us, who,
at his request, in his presence, and in the presence of each other, have subscribed
our names as witnesses hereto.
~~~
F C ~?
~ 1% ~~~
A~„ ~~~F~~FS
MARLIN R. McCALEf3
-5-
F~k~~ 1~, ?'~1 Q:'~A^~ Ph""( Br~1~K 4'2-?'~F_~747
PNC
February 11, 2011 ,
tirlarlin McCaleb
Attorney at Law
219 E Main St
P O Box 230
Mechazaicsburg, FA 17OSS
RE: Charles E Detweiler
SS?~': 195-16-2& 14
DOD: O1-27-2p11
Dear N1r. McCaleb:
In response to your request ror Date of Dwath (DOD) balances for the customer noted above. our
records show the foll_orving:
Checking Account
Account # 5070074248 ,Established: t7 ] -01-] 979
CHAFtI.,F,S E DE1"'WEII.ER
DOD balance: ~ 53}731.55 + 1.40 accrued. interest
Safe l3eposit Boy
The decedent maintained safe deposit box # 146
CHARLES E DEt~VEiLER
Located at:
Hampden Branch
4242 Carlisle Pike
Camp Hill, PA 17~ 11
(717) 730-2200
Please note that this off ce provides date of death balances far deposit accounts (IRAs, CDs, Cheekit~ snd
Savings). Vt~a do not process say financial transactions ®r provide statements. if you need assistance with
any ofthesc items, please caIi 1-S88-PNC-BANK (1-888-762-2365) or stop by your local PNC Bark branch
office.
Sincerely,
National Financial Set'viC,es Center
P'NC Banks 2~.A.
Member FDIC
Page 1 aft
Schedule E.1
I
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This message is intended fir the use of the individual or entity to which it is addressed G~nd mcxY~
cr>rttain information that is privileged, confidential and exerrrpt from disclosure u~zder applicable law.
If the reader of this message is not the intended recipient or the employee yr agent responsible fQr
delivering this message to the intended recipient, you are hrereby noted that arty dissemination,
distribution or copving of this communications is strictly prohibited. If you have received this
communication in error, please rots me immediately by reply or by telephone at ~'~10-76?-1775 and ~
immediately destroy this frayed document.
}'one 2 of 2
I
Schedule E.l
1Jig~y®
~NEILL
]Funeral Home Inc.
l ~~ ~~
~CQ T~ ~~iy
~U.2.,
3501 Derry Street
Harrisburg, PA - 17111-181 7
tel 717 564-2633
fax 717 561-9918
Stephen J. Wilsbach, Supervisor
Ci.C.~r-Q-J
~~~
3401 Market Strect
Camp Hill, PA - 17011-4428
tel 717 737-87?6
fax 717 737-1859
kevin J. Shillabeer, Supervisor
Schedule E.5
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claim containing any materially false information or conceals for.the
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`Owner/Payor (if di Brent fro ms ed
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Social Security Number
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Relationship [o Insured t
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Primary Relationship to Insured -';; Contingent Relationshrp;ito Insured
3. Plan (Check plan & circle payment years.}
?Fu1lBenefitSinglePremium ~uneral
Amou/nt
^ Full Benefit Multi Pay
-:Complete Section 3a. 3 5 10 ?
$ -"-~f ~ ~
0 Graded Death Benefit* ,
Completesections3aand3b
':= 5 IO
~ 'i_ -- Inittal Face Amount `'
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S ~ '
^ FlexiblePlan 3 5
Initial Payment
AnntiitY `~; ~ SP ; `5 $~ ~ ,~~ ~ ~, ;
,~ Graded Death Benefit (% of Initial' Face Amount) `' '
Year S-Pay L0-Pay Periodic Payment
` 1 4D% 30%.,. Amount
3+ Death Benefit Equal to Cutrent Face Aatoiint ~
4.'Inifial Payment Optior
~ O Check (Payable to AIyII.).
^ Visa ^ Master Card- (Ple<
Account #
Cardholder's Printed Name
Cardholder's .Signature _
5: Billing In;f~nrrnation
^ :Money Order (Payable to. AML)`.
complete information below.)
Exp. Date ,
Payment Mode: ^ Annual ^.Semi:.'^ Quarterly ^ Monthly.
Billing Mode: ^DirectBill ^PAC* PACDate
"`Complete:aection 5a..
.+a. r ~ c.,uu wuccu ~.ne~K YHSr In70rmailOn: Subse uentBe ments
Name of Bank
Choose One: ^Checking ^ Savings
Routing Number Account Number
Signature of Account Holder
7. Agreement
3a. Healtn Wuest~ons (I'o be Cbm Meted i5y Proposed Insured)
Please read Questions A, B & C and respond by initialing the appropriate line
below.,(If the answerto all questions is "No," apply for Fu1lBenefit Multi Pay
policy. If-any answer is "Yes," proceed to question 36.)
A. Within[helastfive{5)years;--haveyou(theproposedinsured)beendiagnosed.
'with or received treatmentfrom a member of the medical profession'for any:
of the following: `
Cancer (other tharrskin cancer). Cirrhosis of the liver
.Congestive heart failure Dementia
Acquired Immune Deficiency Syndrome (A Q)S) Paralysis
AIDS Related Complex- ` Seizures
Diabetes (over 80 units of insulin daily}
Xes No,
B: Within the last two (2)years; have you (thepmposed:insured)bBen diagnosed
with' or received treatment from a member of the medical profession for any
of the;foIlowing:,_
Alzheimer's Disease Open heart surgery
Lung disoi•derregtiiring oxygen Stroke
Kidney failure Heart attack
Yes No
C. Are you (theproposed insured) currently hospitalized, scheduled for major.
surgery, or the recipienf.of an organ transplant?
Yes No
Proposed Tnsured's Primary Care`Physician (OPtional)
3b. Health Questions To be com feted by Proposed Insured)
Please read and- respond to the question below by initialing the appropriate line.
(If the answer m question is "Yes;" no coverage is available:.If the answer is "No,"
apply .for the: Graded Death Benefit policy)
Have you beem diagnosed as having a terminal illness which is expected to result
in death within the:nexrsix (6) months? _ yes No
6. tie IaCement
Will the policy that yQU are applying for replace any existing life insurance
or annuity policy? ^ Yes' ,~, No
If.yes; give name and address of the existing insurer and policy number,.
if available: t
The above information is true and complete to the ties[ of my knowledge. Coverage becomes effective according to the terms and conditions as stated in
this application and upon receipt of the first full premium by American Memorial Lifeflnsur,~nce Company.;
I authorize anydoctor, hospital or related"facility; insurance company; person ororganizatron.Ei~ying records of me or my fami: y, ito give American Memorial
Life.insurance Company and its insurers any such information. `I understand that this information may be used to determine eligibility for this insurance. A
reproduction of this authonzatton shall be valyd as..the original. This authorization shall be valid for two (2) years after the effective date.
Signed at: City E-r=~ ,, ,l ` r~ 7-,! rr State ~' >>'~ Effective Date (mo.~day/yr) ~ / ~ Q / j/ .
Proposed Insured Signature _ Owner Signature (ifdifferen. ~'?$~ `~: , ~» .,,,^_
..
8. Agent's Statement - _ ~
Is the insurance applied fQr-S.ntended to replace or change an :existing-life insurance or annuity policy? ^ y~ (<r,.p1o
Ifgthe heal uestion e cpm feted I e tf that the informauon was prgovided diiectly by •the~Pro~ sed Insured. -
q ~ P ~ Y
A ent Si nature r-~f~,-r~, ~ ~';a ~"~; ~:~,..2~~ ~'~ ti .f ~~1~-tij~) J t~~r~ ~ -'~~~Date ~ /.?^G: / ~,'
~~,. i ,= «.~ ., / A ent Printed Name '~
Agent # ~ r- r' ;~ ~~ Funeral Home f~ ~ f ~ ~ .-_._ _, _ CI Location # _ /~ ~.~:'
P-1 ]30-PA-A WHITE -COMPANY YELLOW -AGENT :PINK -FAMILY ~i 12109
Schedule E.5 -=%
ROMBERGER MEMORIALS FOR OFFICE ~~JSE ONLY
Mfgr .................................................... ~ Dare Bought ................. ...:...........
. ,GRANITE -..MARBLE -BRONZE Mfgr. rro ......................
;:
`., Memorials Since 1929 ~ ~ .. Design no ..:...: .:~ :.... ....:.::.:... Found ..... .:::... ._ .... _.,._:..... .
• ,a
Code Mont. ~.:.... , .: .:.
'~ PL,ANT AND DISPLAY --2395 STATE STREET: ,, „ ~ ~ . ..:::...... "T~-rms ..,;:_........Down,payment ~~.
,., ~ ~ B V.P ce wiChm 3fI daysafieF a,mplcuon ;;
IIARRISBURG, PENBRQO
lC; PA 17103 PHONE 232-1147 Code Mkr ..:..... ...:.... .....:.. .. r_rmonth chargcwW,be made'oh all
. , 800-340-6744. ---. Pa~stdue'aceouiits. ..,
` Sect: LIo
_. ,
f
TO.. ~1~:t.1.~:.,. ~. 5., ~ :..............
~.....~:.~.. ~ s ~/.~...~ ys~...~~.~:~~ .....:.:::....:....:.. BATE.~.~~e~'.~W.{.i......::.:......:...
..
ADDRESS ... ~~..t'~ v ~.......~~. ~..~ ........~•:-: ~ :t•;,. ~:~.4: #~1.~..~~...,......Y~L `.~ ..........~..4~. ~.~ ~ ........................... ............._ .........:
ORDER NO ................... DESIGN NO...... ~; ,....... MATERIA.L4;2!~~ . ~,~~ ~1 ~.?.~....... TERMS ..._.........:.........
..............
L' ,_ ~ _.
DIE........:,.a.! ":~ 1.1a~-:.,:.....~../......... ~::~. ~::~~.......:'~.E-.~.f~.~c~'~:- :................... PRICE OF MONUMEIV'I' ............ ...............................
- .:~ :BASE: P.RIEE Off: MARKER ::. .:::~ ~ ~ ~ ~ t~
... CEMETERY FOUNDATIOrf ....... .......... J.+~i G. ,...•,_.._
POSTS- ..... ................ ..:.......~~'~':~..~.....~t~""?/.t,~1--...:.~?~...................
1 E OF LETTERS
- ^~ F ~ ~ LEAVE SPACE FOR..t~•c.~...MORE INSCRIPTIONS TOTAL COST ......................... _. ~~ ~ ~-.
ALL FUTURE LETTERING TO BE EXTRA
~~ ~ `~! _
E"l,ti r~t~.~ ~~,~~~..
.,
__
1 ..:
To be erected in ~Y ~~.~..t--. ~ ~ ~~
................................................Cemetery in ....~~?~.~f.~t..:... J ...~A:......................during
the month of ~~?~ {~ kt... P;~,i;.~.~; k~~..unless unavoidably delayed by labor troubles and other contingencies beyond, our
control and then as soon as practicable thereafter.
Yee- No ~ '. ', „`_. '_ .i_. ... ..
^ ^ ,optional-vandalism protecfion ~:2d'year . lp y~ , •; ,
.. .. r {
The undersigned (hercuaafter kno n as the purchaser) agrees to pay Romberger Memonals „~,..„ ~.
....
----~-~-~ ~~ , C.S` :~,. Dollars
..),.t~~..r`;:T.:~' 1'`:•~tt~~........~~-.Ley.i~;~i,.t.~a ~.i,~:~:. ~.c.~ .........C.~a.~.~s~- .t""'..~....
from date of acceptanc
...................... e.of this order`-
it is further understood that upon acceptance of ttus order the contract so,made cannot be :cancelled, altered or modified by [Lie purchaser, or 6y an-.agent oF,
Romberger Memorials or in any manner except..by agreement in writing between the purchaser and Romberger memorial§, and the :above monument and appurte-
nances are to remain the property of Romberger memorials, until fully paid for with right of removal
~ m
Accepted at_. ~ ~~-,. ................~................................ ate
.......... ~. ) .e ~
.....................1 ........ 4.... ...............................
--
Sold By...... ~.~,:-~......;• ::may }.~ta~ :..(~.r.-- :......................... urchaser . l~.:c.t,<..• ~ f
Schedule E.7
Schedule H.A.2
101 West Big Beaver Road
Suite 1200
Troy, MI 48084
tel 248 740 7100
fax 248 740 9530
toll free 800 227 1931
April 29, 2011
Emily Burbage Russ Ipsen
P.O. Box 357
Lincolndale, NY 10540
RE: Account 213-37999-12
Charles E. Detweiler TOD Emily Ann Russ
Dear Mrs. Burbage Russ Ipsen:
MorganStanley
SmithBarney
As per your request, a list of holdings for the above referenced account has been compiled as of
January 27th, 2011:
Cash $373.74 $ 3.73.74
Cisco Sys Inc. CSCO 100 shares: High $21.490; Low $21.26; Close $21.44 2, 137.50
El Paso EP 1,050 shares: High $15.61; Low $14.45; Close 15.58 I5, 781.50
Intel INTC 100 shares: High $21.94; Low $21.65; Close 21.75 2 , 17 9.50
Pfizer Inc. PFE 1,000 shares: High $18.51; Low $18.27; Close $18.48 18, 390.00
Rite Aid Corp. RAD 3,500 shares: High $1.27; Low $1.13; Close $1.27 4, 200.00
Valero VLO 50 shares: High $25.790; Low $25.045; Close 25.37 1, 270.88
$ 44,333.12
The summar}~/prices/quotes/statistics contained herein are obtained from sources we believe to be
reliable, but are not necessarily complete and cannot be guaranteed. The information contained in yoa~r
monthly account statements and confirmations reflect all transactions processed by MorganStanley
Smithbarney LLC, and as such supersedes all other reports for financial tax purposes. This report does
not supersede or replace your monthly MSSB Client Account Account Statement.
Please call 248-740-7168 if I can be of further assistance.
Sin rely,
~~
Nivy Rapo
Senior Registered Associate
Financial Planning Associate to
Denise C. Markovich
First Yice President
Financial Planning Specialist
Portfolio Manager
Investment Management Consultant
Encl. January Statement
Soh°dul~-r.l
Morgan Stanley Smirh Barney LLC. Member SIPC.
r
Neill Funeral Home ~~~ ~~
02/07/2011
Emily Ipsen
PO Box 357
Lincolndale, NY 10540
SECTION I SERVICES AND MERCHANDISE
FUNERAL DIRECTOR AND STAFF SERVICES
Minimum Professional Service $ 2,680.00
CARE AND PREPARATION OF REMAINS
Embalming $ 795.00
Other Preparation (Casket, dress, cosmetic) $ 395.00
Refrigeration
USE OF FACILITIES & RELATED STAFF CHARGES
Visitation
Funeral Ceremony $ 395.00
Church Ceremony
Graveside Service
IRANSPOI~T,ATION
Transferring Remains to Funeral Home $ 495.00
Funer'aFVehicle -Hearse $395
Limousine/Family Vehicle
Service/Flower Vehicle $ 395.00
Transfer to Crematory
MERCHANDISE
Casket $ 2,195.00
Outer Burial Container $ 995.00
,,
,;;~
t _ ~.~
_~F f
~~
Services for: Charles Detweiler
Service Contract: 741101000232
Date of Service: February 4, 2011
SECTION II CHARGES MADE ON YOUR BEIiAt_F
Patriot News Obituary $ 332:12
Flowers $300.00
Certified Copies of Death Certificate $ 120.00
Clergy Honorarium $ 150.00
Musicians (organisUsoloist)
Cemetery Equipment $ 159.00
Evergreen Cemetery $ 800.00
New York Hearse Driver
TOTAL SECTION II $ 1,861.12
SECTION III OTHER
insurance Allowance $ (150.01)
Manager Approved Allowance $ (449.99)
Dignity VFW Components
TOTAL SECTION III
SECTION IV TAX
TOTAL SECTION IV $ _
Alternative Container
Urn
Clothing
OTHER GOODS AND SERVICES
Memorial Package _ $40.00
Memorial Folders/Cards
Memorial-Book
Fldwers. ,.: ,..,. .,
TOTAL CHARGES $ 10,041.12
Less Payment of
Less National Cremation Society _$ (9,711.00)
Balance Due $ 330:12
_ _. _
TOTALSECTIONi: $ 8,780.00 - ___
Dignityn
MEMOIl1AL
3501 Derry Street • Harrisburg, PA 17111 • 717-564-2633 • Fos 717-561-9918 • Stephen J. Wilsbach, Sup.
3401 Market Street • Camp Hill, PA 17011 • 717-737-8726 • Fax 717-737-1859 • Kevin J. Shillabeer, Sup.
DignityMemorial.com
~rhedul~ H.A.l
•
~.. - ~1
V'~ l..`_I~AC` ~
100 MOUNT ALLEN DRIVE, MECHANICSBURG, PA 17055
EMILY RUSS
PO BOX 357
3 VERONA PLACE
LINCOLNDALE, NY 10540
Form PB-01
RESIDENT # UNIT' STMT. DATE
41009 321 _ 01/31/2011
RESIDENT S
Mr. CHARLES E. DE7CWEILER
TOTAL AMOUNT DUE $4 009.13
DATE DUE _ 02/28/2011
DATE DESCRIPTION RATE Days/
Units CHARGES CREDITS BALANCE
Balance Forward __
3,084.65
01/21/2011 PAYMENT RECEIVED -THANK YOU!!! 3,084.65 0.00
*** Nursing Care ***
01/01/2011 MOTION MONITOR 01/18-01/24 1.13 1.00 1.13 1.13
01/01/2011 MEAL CREDIT -9.00 26.00 234.00 -232.87
01/17/2011 DAILY PHONE CHARGE (WAGNER) 1.00 17.00 17.00 -215.87
01/01-01/17
01/24/2011 RM/ BRD -NURSING -SEMI-PVT 299.00 7.00 2,093.00 1,877.13
01/18-01/24 .
*** Enhanced Living ***
01/26/2011 ELPS -DELAWARE SINGLE 82.00 26.00 2,132.00 4,009.13
01/01-01/26
RESIDENT # CURRENT OVER 30 OVER 60 OVER 90 OVER 120 TOTAL AMOUNT DUE
41009 4,009.13 0.00 0.00 0.00 0.00 $4,009.13
Kt51uEN I NAME Mr. CHARLES E. DETWEILER Form PB-01
N!A
Please make check payable to Messiah Village.
A 1 % finance charge may be assessed on accounts for which payment has not been received by the due date.. Thank you!
If you have any questions or concerns about your bill, please address them directly to Fiscal Services at 790-8220. Thank You!
Schedule I.L