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HomeMy WebLinkAbout10-20-11COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT DUPLICATE DOUGLAS GEORGE F III SALZMANN HUGHES 354 ALEXANDER SPRING ROAD CARLISLE, PA 17015 fold ESTATE INFORMATION: SsN: 276-22-9013 FILE NUMBER: 211 1-0231 DECEDENT NAME: BOLLINGER RONALD B DATE OF PAYMENT: 10/ 20/ 201 1 POSTMARK DATE: 10/20/201 1 COUNTY: CUMBERLAND DATE OF DEATH: 02/ 15/201 1 ACN ASSESSMENT CONTROL NUMBER REV-1162 EX(11-961 NO. CD 015088 AMOUNT 101 ~ 5416.50 TOTAL AMOUNT PAID: REMARKS: SEAL CHECK#5732 5416.50 INITIALS: HEA RECEIVED BY: GLENDA EARNER ST'~RASBAUGH REGISTER OF WILLS REGISTER OF WILLS INVENTORY REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA COMMONWEALTH OF PENNSYLVANIA } SS COUNTY OF Cumberland File Number 21-11-0231 J. Delores Gusler, Patricia A. Lindeboom and Susan A. Rhea Personal Representative(s) of the Estate of Ronald B. Bollinger deceased, depose(s) and say(s) that the items appearing in the following inventory include all of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation planed opposite each item of said inventory represents its fair value as of the date of the decedent's death, and that Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which ap in a me randum at h nd of is inventory. I verify that the statements made in this Inven- tory are true and correct. I understand that false state- J, p Gu ler~ ~ , ments herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to ~ pa ici . Lindeboo nn G ~C/ l~'~f authorities. ~J ~~~i1C,J ~ ' /'(.~ Susan A. Rhea Attorney - (Name) (Firm) (Address) (Telephone) George F Douglas, III Esq. (Supreme Court I.iD. No.) 61886 Salzmann Hu hes P.C. 354 Alexander S rin Road Suite 1 Carlisle PA 17015 717_249-6333 DATE OF DEATH LAST RESIDENCE Bethany Village, Maplewood No. 326 02/15/2011 Mechanicsburg, PA 17055 Personal Prooertv Cash ................................... FIGURES MUST BE TOTALED Personal Property ........................................................................ Stocks/Listed ................................................................................ Stocks/Closely Held ..................................................................... Bonds ............................................................................................ Partnerships and Sole Proprietorships ..................................... Mortgages and Notes Receivable ............................................... All Other Property ........................................................................ Total Personal Property ........................................ Total Real Property ................................................ Total Personal and Real Property ........................ DECEDENI"S SOC. SEC. NO. 276-22±9013 7`30 19 , o - ~~ ~~ ~ ~ ~ rrt C, ~ TJ ~ !!~ •_; ==~ ~ m rv ~ , ~'; :_ v% ~- _ _ 1. ,~~ ' . .11,~ _F..) - ,. - f_ r _ ....Y •.._ ~ . _s~ .. _._ __ ~~ ~ - ~ ~ 1.. rl ~ cs ``~ G - ~..., ~, 19,765.30 .19,165.30 NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may at the election of the personal representative include the value of each item, but such figures should not be extended into the total of the Inventory. (See X20 Pa. C.S. § 3301(b)) Form RW-09 Rev. ~o-~s-zoos REGISTER OF WILLS OF INVENTORY CUMBERLAND COUNTY, PENNSYLVANIA COMMONWEALTH OF PENNSYLVANIA } SS COUNTY OF Cumberland File Number 21-11-0231 DECEDENTS $OC. SEC. NO. DATE OF DEATH LAST RESIDENCE Bethany Village, Maplewood No. 326 n~~4~~9M4 Machanicsbuw. PA 17055 276-22-9p13 ~aS.h Asbury Communities, Inc. -refund 2,890.25 Commonwealth of Pennsylvania -Bureau of Unclaimed Property, utility refund from 57.22 Embarq Land Service -property purchase before death 697.00 Mass Mutual -payment 547.46 PNC Bank, Free Checking Account No. 5140423737 515.17 PSECU, Certificate of Deposit No. C54 1,511.40 Accrued income on above item through date of death 0.49 PSECU, Certificate of Deposit No. C55 1,512.94 Accrued interest on above item through date of death 0.49 PSECU, Checking Account No. S04 1,284.13 Accrued interest on above item through date of death 0.20 PSECU, Money Market Account No. S07 6,823.48 Accrued interest on above item through date of death 1.18 PSECU, Regular Share Account No. S01 5.14 The Patriot-News Co. -refund 229.75 US Treasury - VA Benefit 541.00 (Attach additional sheets if necessary) Total Personal Properly and Real Estate 19,765.30 REGISTER OF WILLS OF INVENTORY CUMBERLAND COUNTY, PENNSYLVANIA COMMONWEALTH OF PENNSYLVANIA } SS couNTY of Cumberland File Number 21-11-0231 DATE OF DEATH LAST RESIDENCE Bethany Village, Maplewood No. 326 DECEDENTS $OC. SEC. NO. 02/1512011 Mechanicsbu PA 17055 276-22-9p13 US Treasury - 2010, 1040 income tax refund 900.00 US Treasury - CSF lumpsum payment 648.00 US Treasury - 2009, 1040 income tax refund 900.00 US Treasury - 2008, 1040 income tax refund 900.00 Total Cash 19,765.30 -2- 1505610143 • REV-1500 Ex (or-to) ifi OFFICIAL USE ONLY PA Department of Revenue Pennsylvania County Code rear File Number Bureau of Individual Taxes °E'ueT~r+roFagvaru` Po Box.2aosot INHERITANCE TAX RETURN 21 11 0231 Harrisburg, PA 17128-OS01 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Date of Birth Social Security Number Date of Death 276 22 9013 02 15 2011 11 10 1927 Suffix Decedent's First Name MI Decedent's Last Name B BOLLINGER RONALD (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS MI FILL IN APPROPRIATE OVALS BELOW rn t l R ^ 3, Remainder Return (dale of death 1. Original Return ^ u e 2. Supplementa prior to 12-13-82) ^ 4. Limited Estate ^ qa. Future Interest Compromise (date of death after 12-12-82) ^ 5. Federal Estate Tax Return Required ^x 8 Decedent Died Testate f Will) ^ 7. ~Atl~a deg cpyint 7rr~st)a Living Trust ch G of ~ 8. Total Number Of Safe Deposit Boxes (Attach Copy o ^ 9. Litigation Proceeds Received ^ C t ~f 10• Sb~°"tWe n1pl~~i ~i anattla~5) death ^ 11. ~A~~ ~ 0~ ntler Sec. 9113(A) HIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE BE DIRECTED TO: AND CONFIDENTIAL T ~ CORRESPONDENT -T D time Telephone Numbe y Name GEORGE F DOUGLAS. III ESQ 717 249 5333 First line of address 354 ALEXANDER SPRING RO Second line of address City or Post Office State ZIP Code CARLISLE PA 17015 REGISTER OFr11~VILLS USE C.Y C7 .. - r. ~~ Zi _ `%. C.7 ---1 c = -- - ~ c ~: ~ ,~ .. i .--, ~ -3 1~3C~`~r ,. - ' DATE~~(1= D ---- ._ . ~ -- ~- f, r~~_r ~~ T7 -.- r -' `!" ~"j dou las salzmannhughes.com Correspondent's a-mail address• g g li is Vue~aoarr~ecsK and oomple e~De~da~ration of preeparer~otlier than tmFre perusonalar~ sentalt~ve sbased on aldl niform lion of whl~ch~prepar$r has any knowledge.~t~er DATE J. Delores Gusler hton Place Mechanicsbur PA 17055 DATE OF PREPARER OTHER THAN REP~j ESENTATIVE ~„ ,. ~ S~~-, .... l~n . _ '~: George F Douglas, III Esq. ~~ (, q ~ 354 Alexander S rin Road, Suite 1, Carlisle, PA 17015 Side 1 1505610143 1505610143 J PA Inheritance Tax Return Signature of Additional Fiduciaries ESTATE OF FILE NWMBER Bollinger, Ronald B. 21-11-0231 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. Signature #2 ~~ ~ Name Patricia A. Lindeboom Address1 1750 Dou las Dr. Address2 City, State, Zip Carlisle PA 17013 Date ~y ~ ~~ Signature #3 Name Address1 Address2 City, State, Zip Date Susan A. Rhea 16 McBride Ave. Carlisle PA 17013 1505610243 REV-1500 FJC Decedent's Social Security Number oeceaenesName: Bollinger, Ronald B. 276 22 9013 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. 19 , 7 65.3 0 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested........... . 6. 7. Inter-Vivos Transfers 8 Miscellaneous I~q S paraterBilleing Requested........... u . 7. 211 , 198.53 (Schedule G) 8. Total Gross Assets (total Lines 1-7) .................................................................. ... 8. 230 , 963.83 9. Funeral Expenses 8 Administrative Costs (Schedule H) ..................................... .. 9. 8 , 5 61.16 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............................ .. 10. 2 , 620.95 11. Total Deductions (total Lines 9 & 10) ................................................................ ... 11. 11 , 182.11 12. Net Value of Estate (Line 8 minus Line 11) ....................................................... ... 12, 219 , 7 81.7 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. 219 , 7 81.7 2 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 219 , '] 81.7 2 16. 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 0 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 9,890.18 0.00 0.00 9,890.18 REV-1500 EX Page 3 ' C I t Address• File Number 21-11-0231 Decedents omp e e . DECEDENT'S NAME Bollinger, Ronald B. STREET ADDRESS Bethany Village, Maplewood No. 326 5225 Wilson Lane STATE ZIP CITY PA 17055 Mechanicsburg Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) 9,890.18 2. CreditslPayments A. Prior Payments 9,000.00 B. Discount 473.68 Total Credits (A + B) (2) 9,473.68 3. Interest (3) 4, If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) 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) 416.5 Make Check Payable to: REGISTER OF WILLS, AGENT. __ PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPptIATE 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? ............................................................ ^ 0 2. If death occurred after December 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?....... ^ 0 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation ................................................................................................................. ~ PA^RT OF T^HE RETURN. IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT A 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 foir 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 beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1)]. . The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116 (a) (1.3)]. A sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Rev-1508 EX+ (6-88) SCHEDULE E CASH, BANK DEPOSITS, ~ MISC. PERSONAL PROPERTY COMMON WEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Bollin er, Ronald B. 21-11-0231 Include the proceeds of litigation and the date the proceeds were received by the estate. All property Jointlyowned with the right of survivorship must be disclosed on schedule F. ITEM DESCRIPTION NUMBER 1 Land Service -property purchase before death 2 Mass Mutual -payment 3 US Treasury - VA Benefit 4 US Treasury - CSF lumpsum payment 5 PNC Bank, Free Checking Account No. 5140423737 6 PSECU, Certificate of Deposit No. C54 Accrued income on Item 6 through date of death 7 PSECU, Certificate of Deposit No. C55 Accrued interest on Item 7 through date of death 8 PSECU, Checking Account No. S04 Accrued interest on Item 8 through date of death 9 PSECU, Money Market Account No. S07 Accrued interest on Item 9 through date of death 10 PSECU, Regular Share Account No. S01 11 Asbury Communities, Inc. -refund 12 Commonwealth of Pennsylvania -Bureau of Unclaimed Property, utility refund from Embairq VALUE AT DATE OF DEATH 697.00 547.46 541.00 648.00 515.17 1,511.40 0.49 1,512.94 0.49 1,284.13 0.20 6,823.48 1.18 5.14 2,690.25 57.22 Total of Continuation Schedule See attached page TOTAL (Also enter on Line 5, Recapitulation) 19,765.30 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1$00 Schedule E (Rev. 6-98) Rev-1508 EX+ (6-88) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY continued ESTATE OF (FILE NUMBER Bollin er, Ronald B. 21-11-0231 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) Rev-1510 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Bollinger. Ronald B. 21-11-0231 This schedule must be completed and filed if the answer to any of questions t through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY THE DATES O TRANSFERSATTACIITA COPY OF THE DEIED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST ( EXCLUSION IF APPLICABLE) TAXABLE VALUE 1 Mass Mutual Financial Group -Annuity Contract No. 211,198.53 100.000% 211,198.53 PAN9350934; equal beneficiaries are decedents step- daughters -Susan A. Rhea, J. Delores Gusler and Patricia A. Lindeboom SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY TOTAL (Also enter on Line 7, Recapitulation) I 211,198.53 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1900 Schedule G (Rev. 6-98) REV-1151 EXt (10-05- COMM~~1.4TjtDEC EDN~R~AN IA ESTATE OF FILE NUMBER Bollinger. Ronald B. 21-11-0231 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT A, FUNERAL EXPENSES: See continuation schedule(s) attached 1,259.96 B. 1. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address Ciry State Ziq Year(sl Commission paid 2, Attorney's Fees Salzmann Hughes, P.C. 6,000.00 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 319.50 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 981.70 7. Other Administrative Costs See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 8,561.16 SCHEDULE H FUNERAL EXPENSES 8~ ADMINISTRATIVE COSTS Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Bollinaer. Ronald B. 21-11-0231 NUMBER DESCRIPTION AMOUNT Funeral Expenses 1 Patricia Lindeboom -reimbursement for partial payment of memorial 200.00 2 Westminster Cemetery -balance due for grave marker 519.00 3 Westminster Cemetery, LLC -balance due for memorial and installation 540.96 H-A 1,259.96 4 Other Administrative Costs Bonnie K. Miller, Treasurer - 2011 Per Capita tax 9.80 5 Register of Wills -three short certificates 12.00 6 Register of Wills -filing fees 30.00 7 Salzmann Hughes, P.C. -reimbursement for payment to Cumberland Law Journal for legal 75.00 advertising 8 Salzmann Hughes, P.C. -reimbursement for short certificate 4.00 9 Salzmann Hughes, P.C. -closing costs held for income tax preparation, postage and 600.00 miscellaneous contingencies 10 Salzmann Hughes, P.C. -reimbursement for Fed Ex mailing 20.50 11 The Sentinel -Legal advertising 212'40 12 Vital Records - 2 death certificates ordered 18.00 H-67 981.70 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-1572 EX+(72-Da) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, ~ LIENS ESTATE OF (FILE NUMBER Bollinger. Ronald B. 21-11-0231 Report debts Incurred by the decedent prior to death that remalnad unpaid at the date of death, including unreimbursed medical ezpsnses. VALUE AT DATE ITEM DESCRIPTION OF DEATH NUMBER 1 Continuing Care RX -prescription drugs 79.11 2 Continuing Care RX -prescription drugs 523.19 3 Continuing Care RX -prescription drugs 337.36 4 Home Instead Senior Care -home care services for 2/1/2011 to 2115/2011 969.95 5 Mass Mutual -reimbursement for over payment of income due to death on Contract No. 547.46 SPA8510014 6 Pine Street Presbyterian Church -check written prior to death cleared after death 25.00 7 United Insurance -payment 21.50 8 West Shore EMS-BLS -medical service call on 2/212011 117.38 TOTAL (Also enter on Line 10, Recapitulation) I 2,620.95 (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. 12-08) REV-1513 EX+(11.08) SCHEDULE J coM~~~~D „e-~s,r~ANIA BENEFICIARIES ESTATE OF €L~ ia~r FILE NUMBER Bollin er, Ronald B. 21-11-0231 NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT (Words) ($$$) TAXABLE DISTRIBUTIONS [include outright spousal I. distributions, and transfers under Sec. 9116 a 1.2 1 Patricia A. Lindeboom Stepchild 1/3rd Residue 72,817.84 1750 Douglas Dr. Carlisle, PA 17013 2 J. Delores Gusler Stepchild 1/3rd Residue 72,815.65 531 Brighton Place Mechanicsburg, PA 17055 3 Susan A. Rhea Stepchild 113rd Residue 72,815.65 16 McBride Ave. Carlisle, PA 17013 I ~ Total ~ 218,449.14 Enter dollar amounts for distributions shown above on lines 15 throw h 18 on Rev 1500 cover sheet as a r 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 TQTAL 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-15Q0 Schedule J (Rev. 11-08) T n ~ , ~ _ ~ ~ ~~ { 7'1 ~ ~ f'3.'t _ ~V a1L I / liJ.~R / ~~ .-.!~ ~.n .. TESTAMENT OF a ~ ~ ~ ;~ ~ ~~ a I, RONALD B. BOLLiNGER, of 8 Tunbridge Lane, Carlisle, Cumberland County, Pennsylvania 17013, being of sound axed disposi~ig iaind, memory and understandingp da hereby make, publish and declare this as and for my Last'USrill and Testament? hereby revoking any and all other wills and codicils heretofore made by me. FIRST. I direct that alI my just debts and funeral expenses be paid from my estate as soon after my death as practically and conveniently maybe done. STCON'D. I direct that my remains be interred within my (amity's burial plot in accord with my expressed wishes. THllZD. I authorize my personal representative to expend funds from my estate, in such amounts as ury personal representative shall consider necessary and desirable for the purchase, erection and inscription of a suitable marker for my grave. FOURT$. I give, devise and bequeath any and all tangible persona( property owned by me at the time of my death unto my three daughters, Fatrici~e A. Lindeboorn, Delores J. Cluster and Susan A. Rhea, in equul shares, per stirpes. FiFTg. I give, devise and bequeath any and all real estate owned by me at the time of my death, unto my three daughters, Patricia A. Lindeboom, Delores J~_ ttusIer and Susan A Rhea, in equal shares, per stirpes. SIKTH. I give, devise and bequeath all the rest, residue and remainder ofrny estate unto my three daughters, Patricia A. Lindeboom, Delores J. Custer and Susan A Rhea, in equal shares, per stirpes. SEY~NTII, I direct that duy a.ud all Tnheritanee, Estate and 'Transfer taxes impaled upon my estate passing under my will or otherwise, shall be paid out of the principal of my residuary estate EIGHTH. Y hereby nominate, constitute and appoint my three daughters, Patricia A. Lindeboom, Delores J. Gusler and Susan A. Rhea as Co-Executors of this my Last '4~ill and Testament. I hereby relieve my Co-Executors from the necessity of pasting sec~zrity in connection with their duties, as such, in any jurisdiction in which they maybe called upon to act insofar as I am able bylaw to do so. In addition to the powers conferred by law, I authorize my Co-executors, in their absolute discretion, to retain in the form received, and to sell either at public or privaxe sale any real or personal property owned by me at the time of my death. 99/80 3Jbd £9L8-~2~OlS Sdfl 3Hl Z0Z656LLZLZ L9~ZZ TtOZ/LI/Z0 ~ T NIl~FT>tT. I have made, or may from time to time make, a wntten memorandum expressing my desire to give certain items of personal property to specific persons. I urge my Ca-Executors and bencficiarics to respcct thcsc wishes. 3ucts a uiGir~uiau~luu~, iCmada, shall be stored in conjunction with this Will. IN WITNESS WAE17E()'~', i have hereuntoa set my hand and seal to this, my Last Will and. Testament, consisting of two typewritten pages this `-E`7'fiay of "`'~Y , 2004. ~. QNALD ~. B4LLYIVG Signed, sealed published and declared by the above named Testator Ronald B. Bollinger as and for his Last Will and Testament, in the presence of us, who, at lus request, iu lsis a3~ht and presence and in the sight and presence of each other, have hereunto subscribed our names as witnesses. ~. , ~.. S~Ib~ ~Stld 69LE-3~IOlS Sdfl 3Hl Z0Z656LLZLZ L9~ZZ TZOZ/LZ/Z0 _ _ _ _ __ (.'UMMUNWEALTH (IF PENNSYL VANIr1 - . SS COUNTY OF CUMBERLAND I, RONALD B. BOLLINGER, Testator whose name is signed to the attached or foregoing instrument, havin;~ been duly qualified according to law, da hereby acknowledge that I signed and executed the instrument as my Last V~ll; that I signed it willingly; and that I signed it as my free and voluntary act far the purposes therein expressed. ~ ~> f ONALU B. BALLING Sworn or aiirmed to and aclcreowltdged boforc me, by Ronald B. Ballinger this i'~"~ay of , 2004. f ~ ~- o F lic CUMMUNWEALT~I OF PLNNSYir VANtA :SS. COUNTY OF CUMBERLAND We, ~ and ~1cl~(~. YYi, ~3i'~t,W~-. the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depbse and say that we were present and saw Ronald $. $ollingCr sign and tactcuto tht instrument as his Last'VVill; that he signed willingly and that he executed as his free and voluntary act for the purposes therein e~cpressed; that each of us in the hearing and sight of the Testator signed the will as witnesses; and that to the best of our knowledge, the Testator was ax that time eighteen (18) or more years of age, of sound mind and under no constraint or undue in$Iuence. Sworn or affirmed to and subscribed befor me by C~C~~° s•~~, ~ and ~ 1m~n~,a ~m ~~3cZx~~ ,witnesses, ~tu51 ~` day or 1~a.~~ , zoo4. otary~bfic I ~~ NOl'RRIAI. SRA ~ Kathy L Mummert, ~Nota public I~orot~h of CarNala, •~w~a Co., Rq ! ~y ~4mm..~ssla~•Ex '~~~~.#~ 59I5~ 3Jdd E9LE-3~IOlS Sdfl 3H1 Z@Z656LLZLT LS~ZZ ZZOZILZIZO PNC t.fAi!!N6 THE WAY March 28, 2011 George F Douglas III Esq. Salzmann Hughes P.C. 3S4 Alexander Spring Rd Ste 1 Carlisle, PA 17015 RE: Ronald B Bollinger SSN: 216-22-9013 DOD: 02-15-2011 Dear Mr. Douglas: In response to your request for Date of Death (DOD) balances for the customer noted iabove, our records show the following: Checldnq Account Account # 5140423737 Established: 01-01-1978 RONALD B BOLLINGER DUD balance: $ 515.17 non interest bearing Loan Account The decedent maintained Loan Account # 4003048109b47939 . For further informatuon and assistance, please contact 1-888-762-2265. Select option 1, then option 3 and then 0 Qzero). After pressing zero, please remain on the line to speak with a Loan Financial Service Consultant. Please mote that this offiice provides date of death balances for deposit accounts (IR.As, CDs, ~hecking and Savings). We do sot proeesa any financis~l transactions or provide statements. If you need assistance with any of these items, please calf 1-888-1?NC-BANK (1-888-762-22b5) or stop by Your local ~1VC Bamlc breach ofFice. Sincerely, National Financial Services Center FNC Bank, N.A. Member FDIC I s l ,,~~~ . ;~ I{ i . ....) K°~'a Page 1 of 2 PSEC~k March 11, 2011 Account # 8679XXXXXX GEORGE F DOUGLAS III SALZMANN HUGHES PC 354 ALEXANDER SPRING RD STE 1 CARLISLE, PA 17015 Dear MR. DOUGLAS III ONALD B BOLLINGER's account with PSECU as of the date of death. The following is the status of R Joint Owner's Name NONE Date of Death 02.15.2011 Date of Birth l 1.10.1927 Share Description Open date Balance Accrued Dividend S 01 Regular Shares 09.28.2007 $ 5.14 13 284 1 $0.00 0.20 S 04 Checking 10.02.2007 2007 02 10 . , 6,823.48 1.18 S 07 Money Market C 54 6 Month Certificate . . 10.14.2008 1,511.40 0.49 C 55 6 Month Certificate 09.01.2009 1,512.94 0.49 The dividend earned. from January 1, 201 l through the date of death was $8.07. The decedent had no loans with us. We do not have safe deposit boxes for our members. We need the executors to sign, date and return the enclosed Authorization to Close Account form before we can close out this account. If you have any questions, please ca11234-8484 in Harrisburg or our toll-free number, (800) 237-7328. At the menu prompt, enter 6 and then extension 2227. Sincerely, r ~~ ~~-~ ~~ Meacie Fairfax Member Service Representative Finance Support Unit Pennsylvania 5tafe Employees Credit Union Main Address: 1 Credit Union Place, Harrisburg, PA 1 71 1 0-2990'• 717.234.8484 • 800.237.7328 Mailing Address: PO. Box 67013, Harrisburg, PA 17106-7013 • 717.777.2100 ~TDD) • 800.472•Pse ulcoro This credit union is federally insured by the National Credit Union Administration. Equal Opportunity Lender Miller, Bridget -- -_ Subject: FW: Cash Value Quote - 9350934 -Created on Mar 15 2011 at 2-36-05-PM. oc Massachusetts Mutual Life insurance Company and affiliates Springfield MA 011 l 1-0001 MassM~a1 FIItANCIAI GItOUP• March 15, 2011 •'"M277':• RONALD B BOLLINGER PO BOX 1022 MECHANICSBURG, PA 17055 Dear Mr. Bollinger: Re:Contract No(s). PAN9350934; Annuitant - Ronald B Bollinger; Issuing Company - CM Life Insurance Co (referred to herein as "MassMutual") - ---------------------------- As of February l5, 2011, the contract's total cash value was $211,198.53. The contract's net surrender value as of February I5, 2011 was $211,198.53. The Total Cash Value is the gross cash value of the contract as of the above referenced date. This value includes net premium payments, plus or minus any interest credit or investment experience, minus the monthly charges and any partial withdrawals. The Net Surrender Value is the Total Cash Value minus any applicable surrender charges and any outstanding policy debt. If you have any questions, please contact our Service Center at 1-800-272-2216. Representatives are available to help you Monday through Friday from 8 a.m. to 8 p.m., Eastern Time. Other contact options include: our website (use the Contact link at www massmutual.com) or your financial services representative, David A Robenolt. Sincerely, Jamie Parslow Jamie Parslow Service Specialist Blue Chip Services cc: David A Robenolt (A037) Registered Representative of MML Investor Services, LLC. and MML Distributors., LLC, a MassMutual Subsidiary. Supervisory office: 1295 State Street, Springfield MA 01111-0001 Massachusetts Mutual Life Insurance Company and affiliated insurance companies. MassMutual Financial Group is a marketing name for Massachusetts Mutual Life Insurance Company (MassMutual) and its affiliated companies and sales reprosentatives. Annuity products are issued by Massachusetts Mutual Life Insurance Company and C.M. Life Insurance Company, 100 Bright Meadow Boulevard, Enfield, CT 06082, is non admitted in New York and is a subsidiary of Massachusetts Mutual Life Insurance Company, 1295 State Street, Springfield, MA 01111-0001. _. _ _ ,, Massachusetts Mutual Life hisurance Company end affiliates Sprin~eld MA Ot 111-0001 1VI~ssMutu.. FINANCIAL QROUP° March 9, 2011 *"*M356**' BRIDGET MILLER EMAIL Dear Ms. Miller: Re: Contract No(s). pAN9350934; Annuitant - Ronald B Bollinger; Issuing Company - CM Life Insurance Co (referred to herein as "MassMutual"} We were recently notified of the death of Ronald B Bollinger. Please extend our sincere sympathy to the family. Our records indicate that Susan A Rhea, step-daughter, Delores J Musler, step-daughter and (Patricia A Lindeboom, step-daughter, in equal shares are the beneficiaries of the above contract. Each beneficiary must sign a separate claim packet, ensuring that the following sections are completed: 1) Thee Annuitant/Owner, 2} Beneficiary Information, 3) Payment Election and 4) Agreement and Signatures Please be sure to indicate each beneficiaries' Social Security Number and whether Federal Income Tax is to be withheld, failure to do so may cause a delay in payment. If Federal Income Tax withholding is elected, State Income Tax withholding will be withheld under relevant state law. The contract will remain invested in the Market until all requirements are received. The actual amount payable is determined when all required claim documents are received in good order. Special attention should be paid to the Payment Election portion of the claim packet as it provides an explanation of all the settlement options. If no option is selected, payment~will be made by lump sum check. A tax advisor should review the settlement chosen so that they may determine the taxable impact. Be aware that proceeds paid under BMA are treated as lump sum distribution for tax purposes. Please return the following requirements to my attention: Completed claim packet Certified death certificate If you have any questions, please contact me directly at (800} 767-1000 extension 21387. Sincerely, Musa ~~ Tina Cowles Claim Consultant USIG Policyholder Services and Claims COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 1 7 1 28-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT REV-1162 EX111-96) NO. CD 015088 DUPLICATE DOUGLAS GEORGE F III SALZMANN HUGHES 354 ALEXANDER SPRING ROAD CARLISLE, PA 17015 fold ESTATE INFORMATION: SSN: 276-22-9013 FILE NUMBER: 211 1-0231 DECEDENT NAME: BOLLINGER RONALD B DATE OF PAYMENT: 10/ 20/ 201 1 POSTMARK DATE: 10/20/201 1 COUNTY: CUMBERLAND DATE OF DEATH: 02/ 1 5/201 1 REMARKS: ACN ASSESSMENT AMOUNT CONTROL NUMBER 101 ~ 5416.50 TOTAL AMOUNT PAID: 5416.50 CHECK# 5732 INITIALS: HEA SEAL RECEIVED BY: GLENDA EARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS INVENTORY REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA COMMONWEALTH OF PENNSYLVANIA couNTY of Cumberland } ss File Number 21-11-0231 J. Delores Gusler, Patricia A. Lindeboom and Susan A. Rhea Personal Representative(s) of the Estate of Ronald B. Bollinger deceased, depose(s) and say(s) that the items appearing in the following inventory include all of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said inventory represents its fair value as of the date of the decedent's death, and that Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that ~ I verify that the statements made in this Inven- tory are true and correct. I understand that false state- ments herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities. Susan A. Rhea Attorney - (Name) George F Douglas, III Esq. (Supreme Court I.D. No.) 61886 (Ff"") Salzmann Hughes, P.C. (address) 354 Alexander Spring Road, Suite 1, Carlisle, PA 17015 (Telephone) 717-249-6333 DATE OF DEATH LAST RESIDENCE Bethany Village, Maplewood No. 326 DECEDENTS SOC. SEC. N0. 02/15/2011 Mechanicsbur PA 17055 276-22-9013 FIGURES MUST BE TOTALED Personal Prooertv C218h ............................................................................................... 19,7'30 Personal Property ........................................................................ ~~ c:~ - - - r-; c - Stocks/Listed ................................................................................ a c ~ , , _. ~ ~ --~ -;~ r- , ~ _ Stocks/Closely Held ..................................................................... T, m rv ~_ ~ u; ca ~ , ,-, -- BOnds ............................................................................................ ~ ; ~ , --, J ~ ~1,._i.. ,'- - P~Irtnerships and Sole Proprietorships ~ -,- ~- _ rv r-~ .-:: ,,, Mortgages and Notes Receivable ............................................... ~ .. r- ~' All Other Property ........................................................................ ~,_., Total Personal Property ........................................ 19,765.30 Total Real Property ................................................ Total Personal and Real Property ........................ 19,785.3U NOTE: The Memorandum of real estate outside the Commonwealth Of Pennsylvania may at the election of the personal representative inGude floe value of each ftem, but uch figures should not be extended into the total of the Inventory. (See X10 Pa. C.S. § 3301(b)) Form RW-09 Rev. 10-13-2006 PA Inheritance Tax Return Signature of Additional Fiduciaries ESTATE OF FILE NUMBER Bollinger, Ronald B. 21-11-0231 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. - Signature #2 ~-~ E~C.~ ` Name Patricia A. Lindeboom Address1 1750 Douglas Dr. Address2 Clty, State, Zip Carlisle, PA 17073 Date ~y ~ ~~ Signature #3 ~~~,Q~ Name Susan A. Rhea Addre$s1 16 McBride Ave. Addre$s2 city, State, Zlp Carlisle, PA 17013 Date L~ l ~ ~ ~~l J 1505610243 REV-1500 EX Decedent's Social Security Number Dacedent'sName: Bollinger, Ronald B. 276 22 9013 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 8~ Notes Receivable (Schedule D) ........................................................ 4. 5• Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............... 5. 19 , 7 65.30 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6. 7. Inter-Vivos Transfers 8 Miscellaneous I~oq Probate Property Se arate Billin Re uested h l S d G p g q ............ ) u ( c e u e 7. 211 , 198.53 8. Total Gross Assets (total Lines 1-7) ..................................................................... g. 230 , 963.83 9. Funeral Expenses 8 Administrative Costs (Schedule H) ....................................... 9. 8 , 5 61.16 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. 10. 2 , 62 0.95 11. T©tal Deductions (total Lines 9 & 10) ........................................:.......................... 11. 11 , 182.11 12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12. 219 , 7 81.7 2 13. Charitable and Governmental BequestslSec 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. 219 , 7 81.7 2 TAX COAAPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable aYthe spousal tax rate, or transfers under Sec. 9116 15 0 0 0 (a)(1.2) X .00 . 16. Amount of Line 14 taxable 219 7 81.72 16 9 8 9 0.18 at lineal rate X .045 ~ . , 17. Amount of Line 14 taxable at sibling rate X .12 0.00 17. 0.00 18. Amount of Line 14 taxable 0 00 18 0 00 • at collateral rate X .15 . . 19. Tax Due .................................................................................................................. 19. 9 , 8 90.18 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ^ Side 2 1505610243 1505610243 REV-1500 EX Page 3 Decedent's Complete Address: File Number 21-11-0231 DECEDENT'S NAME Bollinger, Ronald B. STREET ADDRESS Bethany Village, Maplewood No. 326 5225 Wilson Lane CITY STATE ZIP Mechanicsburg PA 17055 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 9,000.00 473.68 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. 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. (1) Total Credits (A + B) (2) (3) (4) (5) 9,890.18 9,473.68 416.50 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 ............................................................................................................... ^ ^x d. receive the promise for life of either payments, benefits or care? ............................................................ ^ ^x 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without ^ ^ receiving adequate consideration? .................................................................................................................... x 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. 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 beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1)]. . The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116 (a) (1.3)]. A sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Rev-1508 EX+ (g-98) SCHEDULE E CASH, BANK DEPOSITS, ~ MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA MJHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Bollinger, Ronald B. 21-11-0231 Include the proceeds of litigation and the date the proceeds were received by the estate. All property joirklyowned with the right of survivorship must be disclosed on schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Land Service -property purchase before death 697.00 2 Mass Mutual -payment 547.46 3 US Treasury - VA Benefit 541.00 4 US Treasury - CSF lumpsum payment 648.00 5 PNC Bank, Free Checking Account No. 5140423737 515.17 6 PSECU, Certificate of Deposit No. C54 1,511.40 Accrued income on Item 8 through date of death 0.49 7 PSECU, Certificate of Deposit No. C55 1,512.94 Accrued interest on Item 7 through date of death 0.49 8 PSECU, Checking Account No. S04 1,284.13 Accrued interest on Item 8 through date of death 0.20 9 PSECU, Money Market Account No. S07 8,823.48 Accrued interest on Item 9 through date of death 1.18 10 PSECU, Regular Share Account No. S01 5.14 11 Asbury Communities, Inc. -refund 2,890.25 12 Commonwealth of Pennsylvania -Bureau of Unclaimed Property, utility refund from Embarq 57.22 Total of Continuation Schedule See attached page TOTAL (Also enter on Line 5, Recapitulation) 19,785.30 (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. 6-98) Rev-1508 EX+ (8-98) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN continued RESIDENT DECEDENT ESTATE OF (FILE NUMBER Bollinger, Ronald B. 21-11-0231 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) Rev-1510 EX+(g_98) SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TA%RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER Bollinger, Ronald B. 21-11-0231 This schedule must be completed and filed ff 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 THE DATE OF RANSFRER.SATTACNTA COPY OF THE DEIED OR REAL ESTATE. DATE OF DEATH VALUE OF ASSET 96 OF DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1 Mass Mutual Financial Group -Annuity Contract No. 211.198.53 100.000°h 211,198.53 PAN9350934; equal beneficiaries are decedents step- daughters -Susan A. Rhea, J. Delores Gusler and Patricia A. Lindeboom TOTAL (Also enter on Line 7, Recapitulation) I 211,198.53 (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 G (Rev. 6-98) REV-1151 EX+(10.06) COMI~~~DECED~N~RNVAN IA SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF I FILE NUMBER Bollinger, Ronald B. 21-11-0231 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT A. FUNERAL EXPENSES: See continuation schedule(s) attached 1,259.96 B. 1. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zip Year(s) Commission oaid 2, Attorney's Fees Salzmann Hughes, P.C. 6,000.00 3, Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees 319.50 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 981.70 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 8,561.16 Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Bollinger, Ronald B. 21-11-0231 ITEM NUMBER DESCRIPTION AMOUNT Funeral Exgg~g$ 1 Patricia Lindeboom -reimbursement for partial payment of memorial 200.00 2 Westminster Cemetery -balance due for grave marker 519.00 3 Westminster Cemetery, LLC -balance due for memorial and installation 540.98 H-A 1,259.96 4 Other Administrative Costs Bonnie K. Miller, Treasurer - 2011 Per Capita tax 9.80 5 Register of Wills -three short certificates 12.00 6 Register of Wills -filing fees 30.00 7 Salzmann Hughes, P.C. -reimbursement for payment to Cumberland Law Journal for legal 75.00 advertising 8 Salzmann Hughes, P.C. -reimbursement for short certificate 4.00 9 Salzmann Hughes, P.C. -closing costs held for income tax preparation, postage and 600.00 miscellaneous contingencies 10 Salzmann Hughes, P.C. -reimbursement for Fed Ex mailing 20.50 11 The Sentinel -Legal advertising 212.40 12 Vital Records - 2 death certificates ordered 18.00 H-B7 981.70 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) COMMONWEALTH OF PENNSriVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, ~ LIENS ESTATE OF FILE NUMBER Bollinger, Ronald B. 21-11-0231 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 Continuing Care RX -prescription drugs 79.11 2 Continuing Care RX -prescription drugs 523.19 3 Continuing Care RX -prescription drugs 337.36 4 Home Instead Senior Can: -home care services for 2/1/2011 to 2/15/2011 969.95 5 Mass Mutual -reimbursement for over payment of income due to death on Contract No. 547.48 SPA8510014 6 Pine Street Presbyterian Church -check written prior to death cleared after death 25.00 7 United Insurance -payment 21.50 8 West Shore EMS-BLS -medical service call on 2/2/2011 117.38 TOTAL (Also enter on Line 10, Recapitulation) I 2,620.95 (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. 12-08) SCHEDULE J COMM~V ~4TQIF~~~VANIA ~~` BENEFICIARIES ESTATE OF FILE NUMBER Rollin er, Ronald B. 21-11-0237 NAME AND ADDRESS OF RELATIONSHIP TO DECEDENT SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(Sl RECEIVING PROPERTY (Words) ($$$) I TAXABLE DISTRIBUTIONS [include outright spousal • distributions, and transfers under Sec. 9116 a 1.2 1 Patricia A. Lindeboom Stepchild 1/3rd Residue 72,817.84 1750 Douglas Dr. Carlisle, PA 17013 2 J. Delores Gusler Stepchild 1/3rd Residue 72,815.65 531 Brighton Place Mechanicsburg, PA 17055 3 Susan A. Rhea Stepchild 113rd Residue 72,815.65 16 McBride Ave. Carlisle, PA 17013 Total 218,449.14 Enter dollar amounts for distributions shown above on lines 15 throw h 18 on Rev 15 00 cover sheet as a ro 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 DOVER Slut I I Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-OS) t"~ ~" x7 -r -~ ~ ~ n ~ rs ~ ^, J r ,~ ~+ r Lfi~l ~L~ t ~ ~ ~ f eke c ° --~ ~" ~f j ~= T~STAM~N~' Off' ~ ~ ~: ;~ ~- ~~ a N ~ I, RONALD B. SOLY~11~iGER, of S Tunbridge Lane, Carlisle, Cumberland County, Pennsylvania 17013, being of sound and disposing mind, memory and understanding, do hereby make, publish and declare this as and for my Last 'UVill and Testament, hereby revol€ing any and all other wills and codicils heretofore made by me. FIRST. I direct that alt my just debts and funeral expenses be paid from my estate as soon after my death as practically and conveniently maybe done. SECOIV'D. I direct that my remains be interred within my family's burial plat in accord with my expressed wishes, T$IRD. I authorize my personal representative to expend funds from my estate, in such amounts as ury personal representative shall consider necessary and desirable for the purchase, erection and inscription of a suitable marker for my ,grave. FOURTH. I give, devise and bequeath any and all tangible personal property owned by me at the time of my death unto my three daughters, Patricia, A. Lindeboorn, Delores J. t~ualer and Susan A. Rhea, in equul shares, per stirpes. 1~IFTg. I give, devise and bequeath any and all real estate owned by me at the time of my death, unto my three daughters, Patricia A. I.indeboom, Delores )~. Cusler and Susan A Rhea, in equal shares, per stirpes. SIXT$. I give, devise and bequeath all the rest, residue and remainder of my estate unto my three daughters, Patricia A. Lindeboorn, Delores J. Gusler and Susan A Ythea, in equal shares, per stirpes. SE VENTII, T direct tlxac auy afi~i all Inheritance, Estate and T'rar~sfer taxes imposed upon my estate passing under my will or otherrHise, shall be paid out of the principal of my residuary estate EYGHT$, Thereby nnmin~tte, constitute and appoint my three daughters, Patricia A. Lindeboom, Delores J. Gusler and Susan A. Rhea as Co-Executors ofthis my Last mill and Testament. I hereby relieve my Co-Executors from the necessity of posting sec~zrity in connection with their duties, as such, in any jurisdiction in which they maybe called upon to act insofar as I am able by law to do so. In addition to the powers conferred by law, I authorize my t=:o-executors, in their absolute discretion, to retain in the form received, and to sell either at public or private sale any real or personal property owned by me at the time ofmy death. 9afE0 ~Jtid E9L8-31015 Sdfl-3Hl Z0Z656LLZLT L9~ZT TIOZfLTfZO NIl'dI'H. I have made, or may from time to time make, a wntten memorandum expressing my desire to give certain items of personal property to specific persons. I urge my Co-Executors and berleflciarics to respcct thcsc wishes. Sucla a IuGIIlulillltluIIl, ITmi3cle, Sha11 be stored In conjunction with this Will. IN WITNESS WI~l7~'(?~~', i have hereunto set my hand and seal to this, my Last'W'ill and Testament, consisting of two typewritten pages tYli~ `{'71'day of j' , 20Q4. /• ' R C1NALp B. BOLL~TG Signed, sealed published and declared by the above named Testator Ronald B. Bollinger as and far his Last Will and Testament, in the presence of us, whu, at llis requcsl, iII Isis s~gtlt dnd presence and in the sight and presence of each other, have hereunto subscribed our names as witnesses. ,,..~ 99/b0 3Jt7d 69L8-3~IOlS Shcl 3Hl Z~Z696LLZLT L9~ZZ TZ9Z/LZ/Z0 __ _ _ __ ~ (,'UMMUNy~EALTH OF PENNS~',G fftiNlA . SS COUNTY OF CUMBERLAND I, RONALD B- BOLLINGEIt, Testator whose name is signed to the attached. nr foregoing instrument, having been duly qualified according to law, da hereby acknowledge that I signed and executed the instrument as my Last wll; that I signed it willingly; and that Y signed it as my free and voluntary act far the purpases therein expressed. lr ~ 1 gNALD B. BOLLING Sworn ar ai~irmed to and aclazowlcdgcd bcforc mc, by Donald $-Bollinger this f~{~~'day of , 2004. f ~ L- o F lic COMMCNI'~EALTl~ OF FL11(NSYL ~ANtA :SS. COUNTY OF CUMBERLAND We, ~ ~ and pyy~(~, lYl~ ~~~u~ the witnesses whose names are signed to the attached. or foregoing instrument, being duly qualified according to law, da depose a11d say that we were present and saw Ronald $. $ollingcr sign and Cacccutc tho instrument as his Last'VVill; that he signed willingly and that he executed as his free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testator signed the wil! as witnesses; and that to the best of our knowledge, the Testator was at that time eighteen (18) or more years of age, of sound mind and under no constraint or undue influence- L r~~~1~~ ,. Sworn or affirmed to and subscribed befor me by ~~ ~.i~w,~ and I(Y1~YIC~,.a ~' ~Ca~ ,witnesses, otary T~bfic f -- r~ata~ia~ spa Kathir L. Mummert, N pgblic ' ~orouph of CarUale, ~ Co., ~P11 1 ;u1Y ~a~mis~lo4' ~ 'i~l~ 89190 3~dd E9LE-3~IOlS Sdfl 3Hl Z9Z656LLZLT L9~ZZ ZZOZILI/Z0 ~P~~ t,~Atl8~16 TKE WAY March 28, 2011 George F Douglas III Encl. Salzmann Flughes P.C. 3S4 Alexander Spring Rd Ste 1 Cazlisle, PA 17015 RE: Ronald B Bollinger SSN: 276-22-9413 DOD: 02-15-2011 Dear Mr. Douglas: In response to your request for Date of Death (DOD) balances for the customer noted above, our records show the following: Checking Account Account # 5140423737 Established: 01-01-1978 RONALD B BOLLINGER DOD balance: $ 515.17 non interest bearing Loan Account The decedent maintained Loan Account # 4003048109647939 . For further information and assistance, please contact 1-888-762-2265. Select option 1, thea~ option 3 and then 0 (zero). After pressing zero, please remain on the Iine to speak with a Loan Financial Service Consultant. Please mote that this offiice provides date of death balances for deposit accoutns (IRAs, CDs, Checking and Savings). We do aot proceaa any Fnanclal transsetiona or provide atatemenla. If you assistance with any of these items, please call 1-888-PNC-BANK (1-888-762-2265) or stop by Your local PNC Hank branch office. Sincerely, National Financial Services Center PNC Bank, N.A. Member FDIC 7:'-.fr- I s, Page 1 of 2 PSEC~k March 11, 2011 Account # 8679XXXXXX GEORGE F DOUGLAS III SALZMANN HUGHES PC 354 ALEXANDER SPRING RD STE 1 CARLISLE, PA 17015 Dear MR. DOUGLAS III: The following is the status of RONALD B BOLLINGER's account with PSECU as of the date of death. Joint Owner's Name NONE Date of Death 02.15.2011 Date of Birth 11.10.1927 Share Description O en date P Balance 4 Accrued Dividend 00 $0 S O1 Regular Shares 09.28.2007 $ 5.1 13 284 1 . 0.20 S 04 Checking 10.02.2007 2007 02 10 . , 6,823.48 1.18 S 07 Money Market C 54 6 Month Certificate . . 10.14.2008 1,511.40 0.49 C 55 6 Month Certificate 09.01.2009 1,512.94 0.49 The dividend earned. from January 1, 201 l through the date of death was $8.07. The decedent had no loans with us. We do not have safe deposit boxes for our members. We need the executors to sign, date and return the enclosed Authoriaation to Close Account form before we can close out this account. If you have any questions, please ca11234-8484 in Harrisburg or our toll-free number, (800) 237-7328. At the menu prompt, enter 6 and then extension 2227. Sincerely, r , ,,~~ _ , ,~~~ ,~ Meacie Fairfax Member Service Representative Finance Support Unit Pennsylvania State Employees Credit Union Main Address: 1 Credit Union Place, Harrisburg, PA 1 71 1 0-2990 • 717.234.8484 • 800.237.7328 Mailing Address: P.O. Box 67013, Harrisburg, PA 17106-7013 • 717.777.2100 (TDD) • 800.472•pse u tom This credit union is federally insured by the Nationol Credit Unian Administration. Equal Opportunity Lender Miller, Bridget Subject: FW: Cash Value Quote - 9350934 -Created on Mar 15 2011 at 2-36-05-PM.doc Massachusetts Mutual Life Insurance Company and affiliates Springfield MA 011 I I-0001 11~~ssMutual flftNNCIAL dliOllP' March 15, 2011 •••M277••• RONALD B BOLLINGER PO BOX 1022 MECHANICSBURG, PA 17055 Dear Mr. Bollinger: Re:Contract No(s). PAN9350934; Annuitant - Ronald B Bollinger; Issuing Company - CM Life Insurance Co (referred to herein as "MassMutual") As of February i5, 2011, the contract's total cash value was $211,198.53. The contract's net surrender value as of February 15, 2011 was $211,198.53. The Total Cash Value is the gross cash value of the contract as of the above referenced date. This value includes net premium payments, plus or minus any interest credit or investment experience, minus the monthly charges and any partial withdrawals. The Net Surrender Value is the Total Cash Value minus any applicable surrender charges and any outstanding policy debt. if you have any questions, please contact our Service Center at 1-800-272-2216. Representatives are available to help you Monday through Friday from 8 a.m. to 8 p.m., Eastern Time. Other contact options include: our website (use the Contact link at www massmutual.com) or your financial services representative, David A Robenolt. Sincerely, Jamie Parslow Jamie Parslow Service Specialist Blue Chip Services cc: David A Robenolt (A037) Registered Representative of MML Investor Services, LLC. and MML Distributors., LLC, a MassMutual Subsidiary. Supervisory office: 1295 State Street, Springfield MA O11 l 1-0001 Massachusetts Mutual Life Insurance Company and affiliated insurance companies. MassMutual Financial Group is a marketing name for Massachusetts Mutual Life Insurance Company (MassMutual) and its affiliated companies and sales representatives Annuity products are issued by Massachusetts Mutual Life Insurance Company and C.M Life Insurance Company, 100 Bright Meadow Boulevard, Enfield, CT 06082, is non admitted in New York and is a subsidiary of Massachusetts Mutual Life Insurance Company, 1295 State Street, Springfield, MA 01111-0001. Massachusetts Mutual Life Insurance Company and affiliates Springfield MA 01111-0001 M~s~Mutu~1. fINNN.C'IAL 9R'OUP° March 9, 2011 ***M356**` BRIDGET MILLER EMAIL Dear Ms. Miller: Re: Contract No(s). pAN9350934; Annuitant - Ronald B Bollinger; Issuing Company - CM Life Insurance Co (referred to herein as "MassMutual"} We were recently notified of the death of Ronald B Bollinger. Please extend our sincere sympathy to the family. Our records indicate that Susan A Rhea, step-daughter, Delores 7 Musler, step-daughter and Patricia A Lindeboom, step-daughter, in equal shares are the beneficiaries of the above contract. Each beneficiary must sign a separate claim packet, ensuring that the following sections are completed: 1) The Annuitant/Owner, 2} Beneficiary Information, 3) Payment Election and 4) Agreement and Signatures Please be sure to indicate each beneficiaries' Social Security Number and whether Federal Income Tax is to be withheld, failure to do so may cause a delay in payment. If Federal Income Tax withholding is elected, State Income Tax withholding will be withheld under relevant state law. The contract will remain invested in the Market until all requirements are received. The actual amount payable is determined when all required claim documents are received in good order. Special attention should be paid to the Payment Election portion of the claim packet as it provides an explanation of all the settlement options. If no option is selected, payment~will be made by lump sum check. A tax advisor should review the settlement chosen so that they may determine the taxable impact. Be aware that proceeds paid under BMA are treated as lump sum distribution for tax purposes. Please return the following requirements to my attention: Completed claim packet Certified death certificate If you have any questions, please contact me directly at (800) 767-1000 extension 21387. Snincerely, l GK~L 1~41~~d Tina Cowles Claim Consultant USIG Policyholder Services and Claims