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Home My WebLink About03-0565 PETITION FOR PROBATE and GRANT OF LETTERS Estate of a a. ~ t ~..~ ~-_,-. ~ No. C~j-t~k~- ~ also known as To: Register of Wills for the Deceased. County of c u m b e r 1 a n d in the Social Security No. 1 8 5 - 2 8 - 0 6 7'6 Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s~ who is/a~e 18 years of age or older an the execut ~ r named in the last wilt of the above decedent, dated M a _v ~ a ,19 9 9 and codicil(s) dated N / A (state relevant circumstances, e.g. renunciation, death of executor, etc.) Decendent was domiciled at death in ¢um b e r 1 a n d County, Pennsylvania, with k er last family or principal residence at Forest park Nur~n9 Center 700 Walnut Bottom Road, Carlisle. PA 17013 (list street, number and muncipality) Decendent, then 7 $ years of age, died a un e 2 4, , ~ 2 0 0 3 , at Carlisle Regional Medical Center, Carlisle, PA 17013 Except as follows, decedent did not marry, was not (fivorced and did not have a child born or adopted after execution of the will offered for probate; was not the victim of a killing and was never adjudicated incompetent: Decendent at death owned property with estimated values as follows: (If domiciled in Pa.) All personal property $ 4 o, o o o. 0 0 (If not domiciled in Pa.) Personal property in Pennsylvania $ (If not domiciled in Pa.) Personal property in County $ Value of real estate in Pennsylvania $ situated as follows: WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s) presented herewith and the grant of letters · e s t a m e n t a r ¥ (testamentary; administration c.t.a.; administration d.b.n.c.t.a.) theron. Rando 1 n/h A D~'~ ~~ ~o~-~'"-g, PA 17^'~_~9 r~ OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA ~ ss COUNTY OF C~mber~a~d The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner(s) and that as personal represen- tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. Sworn to or affirmed and subscribed </'~,~/' t~' ~ ~ before me this day of [ /" ~ ~' Register ~ No. Estate of J a n e t S . S t r a w , Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW 19__, in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s~ dated M a ¥ 2 4, 1 9 9 9 described therein be admitted to probate and filed of record as the last will of J a n e t $. $ t r a w ; and Letters T e s t a m e n t a r ¥ are hereby granted to R a n d o 1 p h A. S t r a w Register of Wills FEES ~ Probate, Letters, Etc .......... $ Short Certificates( ) .......... $. Jane ~AT~F~t~&~qI~Yx~S~p~t~D~'N°')t 22~55 Renunciation ................ $ o s r TOTAL __ $ Filed ................................... PHONE REGISTER OF WILLS OF c,~-~,-l~na COUNTY OATH OF SUBSCRIBING WITNESS Jane M. Alexander,a~d Narumol Alexander (each) a subscribing witness to the will presented herewith, (each) being duly qualified according to law, depose(s) and say(s) that e_her ~re present and saw Janet S. Straw the testat, rix , sign the same and that they signed as a witness at the request of testat rix in h er presence and (' (in the presence of the other subscribing witness(~fl). ] Sworn to or affirmed_ and subscribed before ~~ me this. /~ ~'/ day of ~q~x'/0I° Alexander ·-J'~-~. - - ~ O~ / ~A ~tain Road, York Springs, PA 17371 -- N~I Ale~der N~ S~ · (Name) M piU,~r~ ~, y~ ~ (Address) REGISTER OV WILLS OV _, OATH OF NON-SUBSCRIBING WITN~S -- :ff~ ~z~ (each) a subscriber hereto, (each) b~ng duly qualified according to law, depose(s) ~ say(s)::.:that familiar with the signature of .~ "'7; codicil testat of (one of the subscribing witnesses to) the will presented herewith and codicil that believes the signature on the will is in the handwriting of to the best of knowledge and belief. Sworn to or affirmed and subscribed before me this day of (Name) 19 (Address) Register (Name) (Address) This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Feepfbr this S278~..21certificate' $2.00 ~,,,~,,~[.~ ::: L~~L°cal Re No. JUN 2 6 2003 Date COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH, VITAL RECORDS .-~P~..,.T CERTIFICATE OF DEATH 8LAC~(iNK 1. Janet S. Straw ] z Female ,. 185 __ 28 __ 0676 ju~ ,~ Cumberland~.v. usu~ ~,~. ~ ~a r i ~ s le~,~ o~ ~us,~s~smv ~ Carl~s lew~ ~.Req~°na 1,. Medical Center ,~'~'"'~"~ ~ ,~. Whit e ,,~ Housewi fo ker ,~ ~*' ,.. Carlisle. PA 17013 ~, Cumberland '~"' ,~.~ ~.,~.~, Carlisle ,,. Lewis Myers ,,. Lottie Bentz i~Mr. Rand~ A. Straw i'""180 Franklintown Road. Dillsburg, PA 17019 ~ ~ c,.~.. ~ ..~.~,,.~s,.,. ~ ~ ,,.June 28. 2003 z,. Dillsburg Cemetery ,,. Dillsburg, PA ' 17019 June 24, 2003 ~[~ 100 S. High Street, Newville, PA of Janet S. Straw I, Janet S. Straw, of the Township of Franklin, County of York and Commonwealth of Pennsylvania, being of sound mind, memory and understanding, do herewith publish and declare this to be my Last Will and Testament, hereby revoking and declaring null and void any and all Wills and Codicils heretofore written by me. ITEM I. I direct that all my just debts and funeral expenses be paid as soon after my demise as may be convenient to the proper administration of my estate. ITEM II. I order and direct my hereinafter named Executor/Executrix to convert my entire estate into cash at either public or private sale, whenever in his/her discretion it may be most expedient for the proper administration of my estate. In the event of such conversion, I authorize my said Executor/Executrix to execute a good and sufficient Warranty Deed to the purchase of any real estate of which I may die seized, in the same manner and capacity as I could if living. ITEM III. I direct that all inheritance and estate taxes be paid on the proceeds of the above conversion and on all the rest residue and remainder of my estate from the residue of my estate prior to further distribution. ITEM IV. I then direct my hereinafter named Executor/Executrix to distribute all the rest residue and remainder of my estate including the proceeds from the above-mentioned conversion in equal shares among my three (3) children, Randolph A. Straw, Dennis R. Straw and Susanne V. Berkheimer, per stirpes and not per capita. ITEM V. I nominate, constitute and appoint son, Randolph A. Straw, as Executor of this my Last Will and Testament. Should he predecease me or be unable or unwilling to serve, I then nominate, constitute and appoint daughter, Susanne V. Berkheimer, as Executrix in his place and stead. I direct that my Executor/Executrix shall not be required to post bond other than his/her assurance for his/her duties as Executor/Executrix. IN WITNESS WHEREOF, I, Janet S. Straw. have hereunto subscribed my hand to this my Last Will and Testament, this ~~"~day of ~/6~'e.~, / _~-. , 1999. Janet S. Straw - - Page 1 of 2 SIGNED, PUBLISHED and DECLARED by the above-named Janet S. Straw, as and for her Last Will and Testamem in the presence of us, who at her request and in her presence and in the presence of each other, have signed our names as attesting witnesses hereto. ~ " L ' /: .... ' " /,- :'i i: .¥ ,~/ ,j. Page 2 of 2 '03 JUL '14 A8 :~0 JANET S. STRAW TORNEY AT' LAW 148 SOUTH BALTimORE STREET P. O. BOX 421 DiLLSBURG, PeNNSYlVaNia 17019-0421 {717} 432-4514 ~-ax (717} 432-2812 CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: Janet S. Straw Date of Death: june 24, 2003 Will No. 21-03-0565 Admin. No. To the Register: I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on 3 u 1 y 1 7, 2 0 0 3 · Name Address Randolph A. Straw 180 Franklintown Road Dillsburg, PA 17019 Dennis R. Straw P.O. Box 85 Dillsburg, PA 17019 Susanne V. Berkheimer 294 Mine Bank Road Notice has now been given.to all persons entitled thereto under Rule 5.6(a) except CO eet Dillsburg, PA 17019 ~.n Telephone (717) 432-.~.4514 4~ .-~ fid .3 ~- Capacity: · Personal Representative x Counsel for personal representative COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE REV 1162 EX(11 96) BUREAU OF INDIVIDUAL TAXES DEPT 280601 HARRISBURG PA 17128 0601 PENNSYLVANIA RECEIVED FROM: INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 004500 STRAW RANDOLPH A 180 FRANKLINTOWN RD DILLSBURG, PA 17019 ACN ASSESSMENT AMOUNT CONTROL NUMBER 101 $1,877.97 ESTATE INFORMATION: SSN: 185-28-0676 FILE NUMBER: 2103-0565 DECEDENT NAME: STRAW JANET S DATE OF PAYMENT: 10/15/2004 POSTMARK DATE: 10/15/2004 COUNTY: CUMBERLAND DATE OF DEATH: 06/24/2003 TOTAL AMOUNT PAID: $1,877.97 REMARKS: RA STRAW CHECK# 0O93 INITIALS: VZ SEAL RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS ~'~N COMMONWEALTH OF REV-1500 ~-~ .~_. ~ PENNSYLVANIA {~:~¢~? DEPT280601 INHERITANCE TAX RETURN ~~HARRSBURG, PA17128-O60 RESIDENT DECEDENT 2 o 3 o s 6 CCUNTY CODE~E~R NUMBER DECEDENT'S NAME (LAST FIRST AND MIDDLE IN)TIAL) SOC[AL SECURITY NUMBER Z St~, J~et S. 185 ~ - ~76 ~ DATE OF DEATH (MM-DB YEAR) DATE OF BIRTH ~MM DB-YEAR) ~ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE ~ ~/~/~3 ~/0]/1926 REGISTER OF WILLS 0 ' ~ (IF APPLICABLE) SURVIVING SPOUSES NAME (LAST. FIRST AND MDDLE INITIAL) SOCIAL SECURITY NUMBER [] 1 Original Return ,~ 2 Supplemental Return [] 5 Federal EstateTax Return Required [] 6 Decedent Died Testate ~^~tachco;~of,~ill, ~ 8 TotalNumberofSafe Deposit Boxes [] 9 Litigation Proceeds Received THIS =t:,..;I I~N MUST BE COMPLY.it:U, ALL CORRESPONDENCE AND CONFiDENTIAl.TAX INFORMATION sHOULb BE DIRECTED TO: NAME Jane M. Alexander, Esquire 148 ti~re eet FIRM NAME:~f^ppli~b,el DllLsbzrg, PA 17019 TELEPHONE NUMBER (717) 432-4514 1 Real Estate (Schedule A) (1) OFFICIAL USE 2 Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 4 Mortgages & Notes Receivable (Schedule D) (4) 5 Cash, Bank Deposits & Miscellaneous Personal Proper~ (5) 7,024,34 (Schedule E) ' :2 ~ 6 Jointly Owned Property (Schedule F) (6) <~ [] Separate Billing Requested , , --I '"1 7 Inter Vivos Transfers & Miscellaneous Non-Probate Property (7) 37,668.52 ' ' ~ (Schedule G or L) <~ 8 Total 6ross Assets (total Lines 1-7) (8) 44,692.86 LU 9 Funeral Expenses & Administrative Costs (Schedule H) (9) 3,579.00 10 Debts of Decedent, Mortgage Liabilities & Liens (Schedule I) (10) 301.51 11 Total Deductions (total Lines 9 & 10) (11) ~ 3,880.51 12 Net Value of Estate (Line 8 minus Line 11) (12) 40,812.35 13 Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been /13) 0,00 made (Schedule J) 14 Net Value Subject to Tax (Line 12 minus Line 13) (14) 40,812,35 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES ~ 15 Amount of Line 14 taxable at the spousal tax ~ rate, ortransfersunderSec 9116(a)(1 2) x 0 (15) ~ 16 Amount of Line 14 taxable at lineal rate x 0 (16) 1 ~8,'~.~6 40,812.35 45 ~ 17 Amount of Line 14 taxable at sibling rate x .12 ~ 17/ O ¢~) 18 Amount Of Line 14 taxable at collateral rate x 15 (18) X ~ 19 Tax Due (19) ] ~836.~) > · BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < Decedent's Complete Address: rSTREETADDRESS ForesL Paza¢ ;[qtrsJ~.g Center CITY Carlisle I STATE PA ziP 17013 Tax Payments and Credits: 1. Tax Due (Page 1 Line I9) (1) 1,836.~6 2 Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + 8 + C ) (2} 3. Interest/Penaltyifapplicable D. interest 41.41 E Penalty Total Interest~Penalty ( D + E ) (3) 41.41 4. If Line 2 is greater than Line 1 + Line 3, enter the difference, This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference This is the TAX DUE. (5) 1,877.97 A Enter the interest on the tax due (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 1,877.97 Make Check Payable to: REGISTER OF WILLS, AGENT : PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a retain the use or income of the property transferred: [] b retain the right to designate who shall use the property transferred or its income: [] [] c retain a reversionary interest: or [] [] d receive the promise for life of either payments, benefits or care? [] [] 2 If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? [] [] 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. Under pena ties of perJury declare that I have exam ned this return including accornpany'ng schedules and statements and to me best of my knowledge and bel,ef it is true correct and cornple e Dedar~tlon of preparer other than the personal representative is based on all iqformation Of wbch preparer has aqy knowledge SIGNATURE OF PERSPNt~SPONSIBLE FOR FLING RETURN ~,/ DATE ADDRESS ~do~E~ ^, S~:a~, ~xecuto: SIGNATURE OF PREPARE~ OTHER THAN RE~SEN.TATIVE 2 ~ DATE -- / ADDRESS Jane Mf. A3_ex~a~der,-~e .... 148 ~[~tir~re Strc~, Dil]sburg, PA 17019 For dates of death ¢¢,,~r after July 1 1994 and before January 1, 1995 the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% I72 RS §9116 (a)(1.1) 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% [72 P.S §9116 (a) (1 t) (ii)] The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent an adoptive parent or a stepparent of the child is 0% [72 PS §9116(a)(1 2)] The tax rate imposed on the net value ottransfers to or for the use of the decedents lineal beneficiaries is 4.5% except as noted in 72 P.S §9116(1 2) [72 RS §9116(a)(!)] The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [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 + (6-98) ~ SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCERESIDENT DECEDENT TAX RETURN PERSONAL PROPERTY ESTATE OF FILE NUMBER Straw, Janet S. 21 03 0565 Include the proceeds of li~JaOon and the date the p~oceeds were received by the eCate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM ~ VALUE AT DATE NUMBER I DESCRIPTION OF DEATH 1. ~Ciitizens: Bank - checking account no. 610074-73404 5,400.81 2. I Fidelity and Guaranty Life Insurance Co. - annuity policy no. 1585314 (May and June payments) 64.90 3. 1988 Mercury Sdn VIN 2MEBM75F45XT05744 995.00 Sold to Brandon S, Moore 4. Verizon - phone services - refund 14.62 5. PA Department of Revenue - 2003 Tax refund 3,00 6. Holy Spirit Hospital - refund on over payment 150.00 7, Forethought Insurance Co. - refund 396.01 TOTAL (Also enter on line 5, Recapitulation) 7,024,34 (If more space is needed, insed additional sheets of the same size) ---- Checking Account Statement 1-888-910-4100 0 OF 1 Beginning 3uty 09, 2003 through August 07, 2003 US059 BR319 2 1 .1ANET S STRAW C/O RANDY STRAW 180 FRANKLINTOWN RD DILLSBURG PA 17019-9764 Checking s u MMA RY 3ANET S STRAW Balance Calculation 30HN M STRAW Citizens Basic Checking Previous Balance 6,357.81 610074-734-4 Checks .00 - Withdrawals 6,357.81 - Deposits & Additions .00 + Current Balance .00: TRANSACTrON DETAILS -- Withdrawats 6,357.81 Other Withdrawals Date Amount Description 07/11 957.00 Debit Memo 07/23 5,/+00.81 Debit Memo 6,357.81 Daffy Balance .00 UT/11 5,400.81 07/23 .00 ] NI:WS FROM CIT~Z,.,,_ Painting the porch? Rep[acing a window? Borrow $1,000 at only 1% APR with a Citizens Bank EZ Home Improvement Loan. [Z payments ofjust $28.20 per month for 36 months. No application fees or polnts charged. Especla[(y for homeowners with family incomes under $43,000. Certain geographic restrictions may apply. Stop in to your Citizens Bank branch today for details, or ca[[ 1-888-339 8700. CERTIFICATE OF TITLE FOR A VEHICLE ,988 DILLSBURG PA 17019 JANET S STRAW 612 RANGE ENO RI) LOT 85 DILLSBURG PA 17019 If a co-purchaser other lhan your spouse is listed and you want the ~itle {o ID SWORN be listed as "Jolrlt Tenants Wi~h R~gh[ of Sun/ivorship" {On dealh ol one Sarah M. Hancock, Notary PuDII~} IST L'ENHOLDER Olllsburg Boro., York County STREET My Oommiesion Expires June 24, 2006 STATE Z,p REV-1510 EX + tS-98) SCHEDULE G INTER-VIVOS TRANSFERS & COMMONWEALTH OF PENNSYLVANIA INHERITANCE TM RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Straw, Janet S. 21 03 0565 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. I DESCRIPTION OF PR0~ERT~ ~ ITEM , INCLUDETHENAMEOFTHETP, ANSFEREE, THBRRELATIONSHfPTOBECED£NTAND DATE OF DEATH %OFDECD'S, EXCLUSION TAXABLE NUMBER J THSDATEO~TRANSFER A~AOHACOPYOFTHEDEEDFORF~EALESTATE VALUE OFASSET INTEREST j IIFAPPLICABfE) VALUE 1. Pioneer Investments transfered on 6/24/03 accounts 1/3 to each of i,3~ 100. ~ i,35¢.8~ three ch dren: Rudolph A. Straw, Dennis R. Straw, Susanne V. Berkheimer ~ I i Account No. 022-62046-15287 ! 2. 'Pioneer Investments transfered on 6/24/03 accounts 1/3 to each of 14,165.61 100. 14,165.61 !three children; Rudolph A. Straw Dennis R. Straw, Susanne V. Berkheimer Account No. 001-6206426913 3. !Pioneer Investments transfered on 6/24/03 accounts 1/3 to each of 5,081.03! 100. 5,081.03 three children: Rudolph A. Straw, Dennis R. Straw, Susanne V. Berkheimer Account Ne. 007-6206426913 4,380.79 100. 4. I Pioneer Investments transfered on 6t24/03 accounts 1/3 to each of 4,380.79 I three children:Rudolph A. Straw, Dennis R. Straw, Susanne V. Berkheimer. IAccount No. 008-6207280006 5. Pioneer Investments transfered on 6/24/03 accounts 1/3 to each of, 7.251100. three children: Rudolph A. Straw, Dennis R. Straw, Susanne V. BerkheimerI 7.25 IAccount No. 011-6207280006 6. Pioneer Investments transfered on 6/24/03 accounts 1/3 to each ofi 4,668 061100 4,668.06 !three children: Rudolph A. Straw, Dennis R. Straw, Susanne V. Berkheimer! i Account No. 021-6207280006 ~ 7. Pioneer Investments transfered on 6/24/03 accounts 1/3 to each of 2,501.76i 1 00. 2,501 .76 three children: Rudolph A. Straw, Dennis R. Straw, Susanne V. Berkheimeri Account No. 070-6207280006 8. !United of Omaha - annuity Policy No. 8018758 5,506.201100. 5,506.20 1/3 to each of the three children: Rudolph A. Straw, Dennis R. Straw, Susanne V. Berkheimer - _ i TOTAL (Also enter on line 7 Recapitulation) ! $ 37,658.52 (if more space is needed, iesert additional sheets of the same size) July 31, 2003 Jane M Alexander Attorney at Law 148 South Baltimore St PO Box 421 Dillsburg PA 17019-0421 REFERENCE: CORRO# 00126124 A/C# 022-6204615287 A/C# 001 6206426913 A/C# 007-6206426913 A/C# 008-6207280006 A/C# 011-6207280006 A/C# 021-6207280006 A/C# 070-6207280006 Janet S Straw TOD/PA Subject To Sta TOD Rules Dear Ms. Alexander: I am writing in response to your recent correspondence with Pioneer regarding the above referenced accounts. Thank you for taking the time to notify us of the death of Janet S Straw. Please extend our belated condolences to the family. The value of the accounts on June 24, 2003 were as follows: A/C# 022-6204615287 $1,357.82 (131.572 shares @ $10.32 per share). A/C# 001-6206426913 $14,165.61 (426.675 shares @ $33.20 per share). A/C# 007-6206426913 $5,08!.03 (4!7.848 shares @ $!2.!6 per share). A/C# 008-6207280006 $4,380.79 (369.375 shares @ $t 1.86 per share). A/C# 011-6207280006 $7.25 (0.322 shares @ $22.53 per share). A/C# 021-6207280006 $4,668.06 (199.746 shares @ $23.37 per share). A/C# 070-6207280006 $2,501.76 (240.554 shares @ $10.40 per share). This information may be needed for tax reporting purposes and does not necessmsly reflect the valuc of the account upon redemption. Shares are redeemed at thc net asset value in effect at the time the request is received in good order. Pioneer Investment Management General Inquiry Shareholder Services, Inc 800-225-6292 P.O, Box 55014 Retirement PJans Boston, MA 02205 5014 800-622 0176 "Member of the UniCrodito Italiano Banking Group, Register of Banking Groups' I wish to confirm that the accounts arc Transfer ou Death Accounts. The beneficiaries arc as follows: Randy A Straw, Son. //3 Dennis R Straw, Son. 1/3 Susanne V Perkheimer, Daughter. 1/3 Before we can close the accounts, Pioneer requires the following: · A certified copy of the death certificate. The certification (the stamp or seal of the issuing authority) must be original, not photocopied. · A letter of instruction fiTom each of the three beneficiaries instructing Pioneer what they wish to do with their portions of the accounts. Each of the letters MUST STATE "The beneficiary will be responsible for any inheritance tax assessed against the accounts." If you have any questions, please feel free to contact our Customer Service Department at 1-800-225~6292, 8:00 a.m. to 9:00 p.m. Eastern Standard Time, Monday through Friday. Sincerely, Karan Lang Shareholder Correspondent ( Enclosure(s): Retum Envelope iQ) UNITED of OMAHA C,,ntraet Number: 8018758 An.uitant: Jailer S Straw Contract Effective Date: 12/08/1998 Contract Eype: NON QUALIFIFJ) Agenl J~ET S S2'~W Jeffrey E Swope 153 LOG~ ROAD ~112 Centra2 Pennsylvania Div2sion Off~ce DILLS~URG PA 17019 Quarterly Statement Ultrannuity Series V April 01, 201)z~ Io June 31k 2003 Contract Value as of June 30, 2003:$5,380.38 Contract Summary Quarter Year Inception to Date to Date to Date Beginning Value $5,158.17 $5,613.()9 $0.00 Deposits SO.00 $0.00 $10,500.00 Withdrawals $300.00 $600.()0 $5,400.00 Fees $0.00 $0.{ ){ ) $120.0( ) Gain/Loss on Investment $522.21 $367.29 $400.38 Ending Value $5380.38 $5380.38 $5380.38 Surrender Value $5,218.19 $5,218.19 $5.218.19 i Variable Account Summary*' Unit Units Percentage Portflflio Value** Owned** Value of Value Alger Americau Growth 17.705227 32.1570¢) $ 569.35 10.586/,. T. Rowe Ih'ice Eqty Income 20.222941 27.01970 $ 546.42 I0.16~/( T. RDwe Price lutl StDck 9.864540 82.()2641} $ 809.15 15.04'7, Pioneer Mid-Cap Value VCT 15.083634 37.31760 $ 562.89 Fidelity VIP II Index 500 12.189011 67.594[0 $ 823.9l 15.31,// Van Kampen Fixed Income 13.069917 158.27620 $ 2,068.66 38.45c/; Variable Account Totals $ 5,380.38 REV-1511 EX + (12-99) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Str~w, Janet S. 21 03 0566 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Cocklin Funeral Home - lettering 95.d B. ADMINISTRATIVE COSTS: 1. Personal Represemative's Commissions Name of Personal Representative (s) Randolph A, Straw 1,650.0 Sodal Secudty N umber(s)/EIN Number of Personal Repm~entaEwe(s) 200-44-7580 Street Address 180Franklintown Road city Dillsburg State PA Zip 17019 Year(s) Commission Paid: 2004 2. Attomey Fees Jane M. Alexander, Esquire 1,650.0 3. Family Exemption: (if decedeafs address is not the same as daimani's, attach explanation) Claimant None claimed Street Address Relatlanship of Claimant to Decedent 4. Probate Fees Register of Wills 93.C 5. Accountant's Fees S. Tax Retum Preparer's Fees 7. Register of Wills - short certificates 6,¢ 8. Narumol Alexander - witness fee 25.C 9. Register of Wills - filing Inheritance lax and Inventory 25.C 10. Notary fees 20.C 11. Clerk of Orphans' Court - filing fee 15.C TOTAL (Also enter on line 9, Recapitulation) $ 3,579.( (If more space is needed, insert additional shears of the same size) REV*IS12 EX + (6-98) ,~ SCHEDULE I DEBTS OF DECEDENT, COMMONWEALTH OP PENNSYLVANIA INHERITANCETA×RETURN MORTGAGE LIABILITIES, & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Straw, Janet S. 21 03 0565 Include unreimbursed medical expenses, ~ VALUE AT DATE ITEM NUMBER i DESCRIPTION OF DEATH 1, i Dillsburg Agency - Donegal Mutual Ins. Co. - Policy No, PAE048650518 - car insurance - debt of decedent 96,50 2. Kilmore Eye Assodates - debt of decedent 48,03 3. Forest Park Health Center - debt of decedent 2126 4. Straw Auto Center, Inc. - car inspection 135.72 TOTAL (Also enter on line 10, Recapitulation) $ 301.51 mare space is needed, insert additional sheets of the same size) Inventory of the real and personal estate of Janet S. Straw deceased 1. Citizens Bank - checking account no. 610074-73Z~4 5400 2. Fidelity and Guaranty Life Insurance Co. - annuity ~olicy no. 1585314 64 3. 1988 Mercury Sdn VIN 2MB~Y75F45X705744 995 4. Verizon - phone services - refund 14 5. PA Pepart~nt of Revenue - 2003 Tax refund 3 6. Holy Spirit Hospital - refund on over payment 150 7. Forethought Insurance Co. - refund 396 'fOTAL $ 7024 34 COMMONWEALTH OF PENNSYLVANIA '~ COUNTY OF CUMBERLAND j ss: P~ndolph A. Straw being duly ~orn accordl.9 to law, deposes and says fhaf he J~ the V~z~acutor of the ~sfafe of J~et ~. ~tr~ late of ~ ~ ~ro~ , Cumberland County, Pa., deceased end that the wifh;n is an inventory made by ~dol~ A. Str~ ., the saJd ~utor of the enf;re estate of sa;d decedent, consisf~n9 of all the persona~ property and rea~ estate, except rea~ estate outside the Commonwealth of Pennsylvania, end fhaf f~e f;gures opposHe each Dem of the Inventory represent Jf's fa;r value as of the date of decedenf's death. ~ and subscribed before me, ~~ ~ ~ ~~ /~ ~ ~ ~ ~dolph A. Str~'="*°' ' Aa~m.~,.~o, ~l~g, PA 17019 Date of Death ~ .... ~ ~'' ~ '"-' 'J~e ~3 INSTRUCTIONS I. An inventory must be filed wifhln three months after appolnfmenf of personal represenfaflve. 2. A supplement inventory must be filed within fhlrfy days of discovery of addlflona[ assets. 3. Additional sheets may be attached as fo personalty or realty 4. See Article IV, Fiduclarles Act of 1949. BUREAU OF /ND/V/DUAL TAXES INHERITANCE TAX DIVISION PO BOX 28060Z HARRISBURG, PA 17128-0601 CONNONNEALTH OF PENNSYLVANIA DEPARTNENT OF REVENUE NOT/CE OF ZNHER/TANCE TAX APPRA/SENENT, ALLONANCE OR D/SALLONANCE OF DEDUCTIONS AND ASSESSNENT OF TAX PA 17019 DATE ESTATE OF DATE OF DEATH FILE NUNBER COUNTY ACN I 12-ZO-ZOOi STRAN 06-ZI-2003 ZZ 03-0565 CUNBERLAND 101 Aeoun~ Reeii:~ed REV-IS47 EX AFP (09-04) JANET S JANE N ALEXANDER ESI) liBr:S BALTINORE ST pi L' 'SBURG C~) ~., HAKE CHECK PAYABLE AND REHZT PAYHENT TO: ;_~.~.: ~ ~-~ REGISTER OF N~LLS ~ ~.~ CUHBEELAND CO COURT HOUSE ~ k~ ~:~ CARLISLE, PA ~70~ ~ONG~HZS L~ ~ RETAIN LO,ER PORT/ON FOR YOUR RECORDS ~'~[~"~"~' NOTZCE OF INHERITANCE TAX APPRAZSEHENT, ALLONANCE OR DZSALLOHANCE OF DEDUCTIONS AND ASSESSHENT OF TAX ESTATE OF STRAN JANET S FILE NO. 21 05-0565 ACN 101 DATE 12-20-200q TAX RETURN HAS: (X) ACCEPTED AS FILED ( ~ CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSR APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Es~a~e (Schedule A) (1) 2. S~ocks and Bonds (Schedule B) (2) 3. Closely Held S~ock/Partnarship Zn~erast (Schedule C) (3) q. Not,gages/Notes Receivable (Schedule D) (q) $. Cash/Bank Deposi*s/Nisc. Personal Proper*y (Schedule E) (5) 6. Jointly Owned Proper~y (Schedule F) (6) 7. Transfers (Schedule G) (7) 8. To,al Assets APPROVED DEDUCTIONS AND EXENPTZONS: 9. Funeral Expenses/Ada. Cos~s/Nisc. Expenses (Schedule H) (9) 10. Dab~s/Hor~gaga Liabilities/Liens (Schedule 1) (10) 11. Total Deductions 12. Ne~ Value of Tax Ra~urn 7~OZI.31 .00 .00 NOTE: To insure proper .00 credit to your accoun*, .00 subei~ the upper port/on .00 of *his fora wi*h your tax payment. 3,579.00 301.51 (11) 3.88§.51 (la) i0,81Z.35 IF PA/D AFTER DATE ZND/CATED, SEE REVERSE FOR CALCULAT/ON OF ADD/T/ONAL /NTEREST. 15. NOTE: ASSESSNENT OF TAX: 15. Aaoun'l: of Line lq a'l: Spousal ra~e 16. Amouni: of Line lq ~axabla at Lineal/Class A rate 17. Aaoun'l: of Line lq at Sibling ra~a 18. Amouni: of Line lq taxable a~ Collateral/Class B rate 19. Principal Tax Due TAX CREDITS: PAYflENT RECEIPT DISCOUNT (+) DATE NUHBER INTEREST/PEN PAZD (-) 10-15-2001 CDOOt500 (15) .00 x O0 = .00 (16) i0,81Z.35 x 015= 1,836.56 (17) .00 x 12 = .00 (18) .00 x 15 = .00 (19)= 1,836.56 Il ANOUNT PAID 1,877.97 TOTAL TAX CREDZT[ 1,836.56 BALANCE OF TAX DUEI .00 I INTEREST AND PEN. I .00 TOTAL DUE I .00 ( /F TOTAL DUE IS LESS THAN $1, NO PAYNENT /S REQU/RED. /F TOTAL DUE /S REFLECTED AS A 'CREDIT' (CR), YOU HAY BE DUE A REFUND. SEE REVERSE S/DE OF TH/S FORN FOR INSTRUCTIONS.) Charitable/Governmental Bequests; Non-elected 9115 Trusts (Schedule J) (13) . O0 Ne~ Value of Estate Sub5ec~ to Tax (lq) 10,811.35 Zf an assessment ~as issued previously, lines 1~, 15 and/er 16, 17, 18 and 19 ~ill reflect figures that lnclude the total ef ALL returns assessed to date. 37~668.52 (8) It,691.86 RECEIPT FOR PAYMENT ------------------- ------------------- GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17G13 Receipt Date: Rece~pt Time: ReceJ.pt No. : 2/17/2005 10:42:30 1039643 STRAW JANET S Estate File No. : Paid By Remarks: 2003-00565 J ALEXANDER, ESQ RSK ------------------------ Receipt Distribution ------------------______ Fee/Tax Description PaYment Amount Payee Name INH TAX RETURN INVENTORY Check# 0094 Total Received......... 15.00 10.00 ---------------- $25.00 $25.00 CUMBERLAND COUNTY GENERAL FUN CUMBERLAND COUNTY GENERAL FUN <:::J~\~, ~ t\"u.... '~'l:t~ \~ ~~ ~~ - S\..\ 'S . J Date of Death: Admin. No.: Name of Decedent: Will No.: Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: Yesj2f- No 0 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. Ifthe answer to No. I is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes _ No :S=- b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? YesB No 0 c. Copies of receipts, releases, joinders and approval of formal or informal accounts may be filed with the Clerk of the Orphans' Court ( _ and may be attached to this re~ort. Date: ~*.~ ' \j >>-1VE- %Y\ A I- ~ J- A tfJ'-'1J F r{. Name r.n )~? '-S g rr J- OJ? /-J c) R F 3r- t:> J L L -3" J3 ("I\~ C' P "!I J '7 t-JI J' Address I '7 J '/ - ~/? -.:;) - Y"f- / q , ~ Telephone No. Capacity: 0 Personal Representative ....)Kl Counsel for personal representative 'I IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYL VANIA ORPHANS' COURT DIVISION IN RE: ESTATE OF JANET S. STRAW Late of Carlisle Borough File No. 2103-0565 RELEASE KNOW ALL MEN BY illESE PRESENTS, that Randolph A. Straw, Dennis R. Straw, and Suzanne V. Berkheimer, being the beneficiary of Janet S. Straw, acknowledge that we have had and received of and from Randolph A. Straw, Executor ofthe Estate of the said Janet S. Straw, deceased, funds due from the said estate as set forth in the First and Final Account. WHEREFORE, we do, by these presents, remise, release, quit-claim and forever discharge the said Randolph A. Straw, his assigns, heirs, Executors, of the duties of the trust imposed and from all actions, suits, payments, accounts, reckonings, claims and demands whatsoever for or by reason thereof. I "f- IN WITHNESS WHEREOF, we have hereunto set our hands and seals this :?:, - day of \"711: IrtUCt:J ,2005. WITNESS: Dennis R. Straw . ,j ,/1 / / , '..Ju/l.,(rTL.,t.-( y. , \"U~ . :; Suzanne V. Berkheimer C.J <...0 II I COMMONWEALTH OF PENNSYLVANIA : SS. COUNTY OF YORK On this, the .:lS-IJ! day of J/-I1f2-t l.- ,2005, before me, the tAM 0 d ....fJI-I undersigned officer, a Notary Public, personally appeared Rail'" A. Straw sworn to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument and acknowledged that he executed the same for the purpose therein contained. IN WITNEYS WHEREOF, I have hereunto set my hand and notarial seal. My Commission Expires: COMMONWEALTH OF PENNSYLVANIA Notarial Seal HalYard E. Alexander, Notary Public Dillsburg Boro, York CCMIllty My Commission Expires Apr. 23. 2005 Member, Pennsylvania Association of Notaries ~L~ ;Notary Public COMMONWEALTH OF PENNSYLVANIA : SS. COUNTY OF YORK -:;(.J ' On this, the 3 i-day of ~-?'l-7~ , 2005, before me, the undersigned officer, a Notary Public, personally appeared Dennis R. Straw sworn to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument and acknowledged that he executed the same for the purpose therein contained. IN WITNESS WHEREOF, I have hereunto set my hand and notarial seal. My Commission Expires: /tLJ/~ ;Notary Public NoIarial Sell HaI_ B. Ja" ~ ., AIbUc DiIhblD Baro. YG* 0Ji!I.I;y My ComIIIIIsh BlrpjIIsAlr. a 2005 ~ . --- . , 'I ~ COMMONWEALTH OF PENNSYLVANIA COUNlY OF Y oRf:.- ....1 .7'- h--IL." .~ On this, the VI ;'--day of { vLJ~'T". I : SS. , 2005, before me, the undersigned officer, a Notary Public, personally appeared Suzanne V. Berkheimer sworn to me (or satisfactorily proven) to be the persons whose names are subscribed to the within instrument and acknowledged that she executed the same for the purpose therein contained. IN WITNESS WHEREOF, I have hereunto set my hand and notarial seal. ~~~ ~tary Public .. / My Commission Expires: NolariaI. Seal Hal_ B. ~. ., ~ NIIic My~ar:~ft., __.f\.P~~ ;-'1. .. I Cumberland County - Register Of wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 5/18/2005 ALEXANDER JANE M 148 S BALTIMORE ST DILLSBURG, PA 17019 RE: Estate of STRAW JANET S File Number: 2003-00565 Dear Sir/Madam: It has come to my attention that you have not filed the Status Report by Personal Representative (Rule 6.12) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of wills a Status Report of completed or uncompleted administration. This filing is due by: 6/24/2005 Your prompt attention to this matter will be appreciated. Thank You. Sincerely, ~_..e~~~ GLENDA FARNER ~~-RASBAdbH REGISTER OF WILLS cc: File Personal Representative(s) Judge ~ ul\~ t '" . ::: r;a ~ tn (fo- l- CJO...Jf"'- OJ o.......ccol"'l <<~...'" .Q. - ~ 5 :::> u .., ffi z M '" t::)J, t..C~ .... t::)~ -lRg IQ~~ h ~ ~> , t;~ ). 2"" i"'",_.J,--; ~~ ,,' o '-D "" , - ~ ,,- ..,.,.,0 C~r- i:-;(/)..-' :2.-5 -< r/) ;:% ~. \JJ. .-< :z-B'-' ~O::c fJ.J:z ~ COt.:::, 8 ui~U ~ '" c:: '" '" '" '" -;b " d ~ >- if. r- oo (l'l V ~. ~ (rJ ;:s- .::!2 c:rO .,..... If). t- >: 0'-: ,.,.~ rn -< r........ ~ ;:s o ~ 0 ~ ~~-€~ 2~::13 .::. ~ C..-. r.)j) ;j t"1 ~ if) 'U 0 -- ~" :2C<:U U >- " 8 d w-" d ~ 3:! C I; 51 : : - : : : "I o o u rfI (11 I l'J l'l ('I ('l .... ('l - () r.. ,.. S. BERNE SMITH Attorney-aI-Law 107 N. 24'" Slreet Camp Hill, PA 17011-3602 PHONE: (717) 737-6789 FAX: (717) 737-6783 May 31,2005 In re: Anne G. Boens; DOD May 30,2004; SS# 204-18-9054 P A File No. 21-04-0565; File 2004-00565 My File: 3004 >~C) -".):J L, Ms. Glenda Farner Strasbaugh Register of Wills Courthouse 1 Courthouse Square Carlisle, P A 17013-3387 ri', (ri Dear Ms. Strasbaugh: Being filed herewith are the original and one copy of a Supplemental Pennsylvania Inheritance Tax return for the Estate of Anne G. Boens. The assets involved were obtained after the filing of the final Pennsylvania Inheritance Tax return as a result of a settlement with Decedent's long term care insurance company which had originally denied that any payments were due. Also, enclosed is a check in the amount of$845.89 payable to the Register of Wills, Agent, as the additional payment of the Pennsylvania Inheritance Tax owed by the Estate. Please acknowledge receipt of the payment. Finally, my check no. 643 in the amount of$15.00, payable to the Register of Wills is enclosed to pay the filing fee for the Pennsylvania Inheritance Tax return. Thank you for your attention to this matter. If anything further is required, please advise. I have appreciated the fine assistance of your staff. They are excellent. Sincerely yours, .~(j3~~~~71 .' S. Berne Smith Enclosures: cc: Connie L. Boens, Executrix COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT_ 280601 HARRISBURG, PA 17128-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT SMITH S BERNE ESQ 107 N 24TH ST CAMP Hill, PA 17011-3602 _____n_ fold ESTATE INFORMATION: SSN: 204-16-9054 FILE NUMBER: 2104-0565 DECEDENT NAME: BOENS ANNE G DATE OF PAYMENT: 06/06/2005 POSTMARK DATE: 06/03/2005 COUNTY: CUMBERLAND DATE OF DEATH: 05/30/2004 NO. CD 005392 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $845.00 I I I I I I I I TOTAL AMOUNT PAID: $845.00 REMARKS: CHECK#794 SEAL INITIALS: JA RECEIVED BY: REGISTER OF WILLS GLENDA FARNER STRASBAUGH REGISTER OF WillS COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT_ 280601 HARRISBURG, PA 17128-0601 REV-1162 EX{11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT SMITH S BERNE ESQ 107 N 24TH ST CAMP Hill, PA 17011-3602 __nun laId ESTATE INFORMATION: SSN: 204-18-9054 FILE NUMBER: 2104-0565 DECEDENT NAME: BOENS ANNE G DATE OF PAYMENT: 06/06/2005 POSTMARK DATE: 06/03/2005 COUNTY: CUMBERLAND DATE OF DEATH: 05/30/2004 NO. CD 005399 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $.89 I I I I I I I I TOTAL AMOUNT PAID: REMARKS: CHECK#794 SEAL INITIALS: JA RECEIVED BY: REGISTER OF WILLS $.89 GLENDA FARNER STRASBAUGH REGISTER OF WillS - STATUS REPORT UNDER RULE 6.12 Name 0 f Dec ede n t : Janet S. Straw Date of Death: June 24. 2003 Wi 11 No. 21-03-0565 Admin. No. Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captione~ estate: 1. State whether administ=~tio~ of t~e estate is complete: Yes X No 2. If the answer is No, 3~3te when the personal representative reasonably believes t~at the administration will be complete: 3. If the answer to No. 1 is Yes, state the following: a. Did the personal representative file d final account with the Court? Yes No X b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal =epresentative state an account informally to the parties in i~terest? Yes X No d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Cerk of the Orphans' Court and may be attached to this report. ~ M. Alexander. Esquire (Please type or print) 148 S. Baltimore St., Dillsburg, PA 17019 Address ;;...;:- ! .~'. . , :-T'.') (717 l 432-4514 Tel. No. Capacity: Personal~Representative X Counsel for personal representative cd (HAM: rmf/ AM3)