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Home My WebLink About04-0848Register of Wills of Cumberland County, Pennsylvania PETITION FOR GRANT OF LETTERS Estateof Connie D. Gontz also known as , Deceased Clifford G. Gontz Social Security No. 172-46-2709 Petitioner(s), who is/ars 18 years of age or older, appl(ies) for: (COMPLETE 'A' or 'B' BELOVV) [] A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/ars the the Decedent, dated and codicils dated Administre~Qr named in the last Will of State relevant circumstances, e.g., renunciation, death of executor, etc. Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the documents offered for probate; was not the victim of a killing and was never adjudicated incompetent: [] B. Grant of Letters of Administration (c.t.a; d.bn.c.ta; pedente lite; durante absentia; durante minoritate) Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) and heirs: Name Clifford G. Gontz Kelly E. Stine Relationship Spouse Daushter Residence 334 Strohm ~,~.,. Shippensburg, PA 17257 11278 Old M~.i~ Roa Shi~ · sburg, PA . .-~ 17257 (COMPLETE IN ALL CASES:) Attach additional sheets if necessary. L.rl Decedent was domiciled at death in Cumberland County, Pennsylvania with his/her family: _~ : or principal residence at 334 Strohm Road, Shippensbur~, Southampton, Cumberland County .... ,;~ (list street, number, and municipality) C~ ..... " Decedent, then 50 years of age, died 08-16-2004 at Washington County HosDital~ Hagerstown! t~D (Location) Decedent at death owned property with estimated values as follows: (If domiciled in PA) All personal propen'y $ 27~576.00 (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 with this Petition and the grant of lettem in the ~ igned: /~ Clifford G. Gontz 334 Strohm Road Shippensburg, PA 17257 Prepared by the Pennsylvania Bar Association Copyright (c) 2004 focm software only ~ Lackner Group, Inc. Form RW-'I (1991) Oath of Personal Representative Commonwealth of Pennsylvania County of Cumberland The Petitioner(s) above-named sear(s) or affirm(s) that the statements in the foregoing Petition a~re true and correct to the best of the knowledge and belief of Petitioner(s) and that, as ~ersonal representativ~(s).of the Decedent, Petitioner(s)will well and truly administer the estate accord~ ~to~~ ,..,~ ~ Swom to or affirmed and subscribed X ~ ~.~'~"~'~"~,. ~,~ / ?~'"~ ~~ ~,, Clifford. Gontz before me this 1 5""' '- day of Estate of Connie D. Gontz . Deceased Social Security No: 172-46-2709 Date of Death: 08-16-2004 of the Petition on the reverse side hereon, satisfactory proof having been presented before me, IT IS DECREED that Letters [] Testamentary [] of Administration (c.t.a.; d.b.n.c.t.a.; pendente lite; durante absenta; durante rninoritate) are hereby granted to Clifford G. Gontz~ Administrator in the above estate and that the instrument(s) dated described in the Petition be admitted to probate and filled of record as the last Will of Decedent. · ........................................ $ Short Certificate(s) ..................... $ ~. E) (,~ Renunciation .............................. $ Attorney: Jerry A. Weigle, Esquire Affidavits ( ) ........................... $ Extra Pages ( ) .................... $ Codicil ........................................ JCP Fee ..................................... $ Inventory. ................................... $ LD. No: Address: Telephone1 E-Mail: 01624 Weigle & Associates, P.C. t26 East King Street Shippensburg, PA 17257 717-532-7388 Other .......................................... $ TOTAL ............................ $ -'~q, ~)O Prepared by the Pennsylvania Bar Association Copyright (c) 2004 form software only The Lackner Group, Inc. Form RW-I (1991) Register of Wills of Estate of Connie D. Gontz Cumberland County, Pennsylvania PETITION FOR GRANT OF LETTERS arso known as , Deceased Clifford G. Gontz Social Security No. '172-46-2709 Petitioner(s), who is/are 18 years of age or older, appl(ies) for: (COMPLETE 'A' or 'B' BELOW) [] A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/are the the Decedent, dated and codicils dated Administrator named in the last Will of State relevant circumstances, e.g., renunciation, death of executor, etc. Except as follows, Decedent did not marry, was not divorced, and did not have a child bom or adopted after execution of the documents offered for probate; was not the victim of a killing and was never adjudicated incompetent: [] B. Grant of Letters of Administration (c.ta; d.b.n.c.ta; pedente lite; durante absentia; durante minoritate) Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) and heirs: Name Clifford G. Gontz Kelly E. Stine Relationship Spouse Daushter Residence 334 Strohm ~ Shippensburg, PA 17257 11278 Old Roa~ ShipP~nsburg, PA 17257 (COMPLETE IN ALL CASES:) Attach additional sheets if necessary. Decedent was domiciled at death in Cumberland County, Pennsylvania with his/her family Cumb~Rand or principal residence at 334 Strohm Road, Shippensbu~!, Southampton, C(~nty (lint street, number, and municipality) Decedent, then 50 years of age, died 08-'16-2004 at Washington County Hospital, Ha_clerstown~ ti]) (Location) Decedent at death owned property with estimated values as follows: (If domiciled in PA) All personal property $ 27 ~576.00 (If not domiciled in PA) Personal property in Pennsylvania $ (If not domiciled in PA) Personal prope~y 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 with this Petition and the grant of letters in the s form to the undersigned: '~ature / Clifford G. Gontz 334 Strohm Road Shippensburg, PA 17257 Oath of Personal Representative Commonwealth of Pennsylvania County of Cumberland The Petitioner(s) above-named sear(s) or affirm(s) that the statements in the foregoing Petition a~re true and correct to the best of the knowledge and belief of Petitioner(s) and that, as ~/ersonal representativ~(s)..of the Decedent, Petitioner(s)will well and truly administer the estate Sworn ,o or affirmed and subscribed X ~.~.. Clifford. Gontz -- before me this ~ '~'"" "day of Estateof Connie D. Gontz , Deceased Social Security No: 172-46-2709 Date of Death: 08-16-2004 A N D NOW,,~____~.V"~L./~ ~ 15 , ~, in consideration of the Petition on the reverse side hereon, satisfactory proof having been presented before me, IT IS DECREED that Letters [-] Testamentary [~] of Administration (c.t.a.; d.b.n.c.t.a.; pendente lite; durante absentia; durante minoritate) are hereby granted to Clifford G. Gontzr Administrator in the above estate and that the instrument(s) dated described in the Petition be admitted to probate and filled of record as the ~ast Will of Decedent. EES ,e,ere ........................................ , OC' -- · Sho~ Ce~ificate(s) ..................... $ ~. O O Renunciation .............................. $ Attorney: Jer~ A. Wei~le, Esquire Affidavits ( ) ........................... $ Extra Pages ( ) .................... $ Codicil ........................................ $ JCP Fee ..................................... $ Inventow. ................................... $ I.D. No: Address: 01624 Weigle & Associates, P.C. 126 East King Street Shippensburg, PA 17257 Telephone1 717-532-7388 E-Mail: Other .......................................... $ TOTAL ............................ $ --~I~. ~)0 Prepared by the Pennsylvania Bar Association Copyright (c) 2004 form software only The Lackner Group, Inc. Form RW-1(1991) VALID ONLy WITH I]HPRE$SED SEAL DATE ISSUED; AUG 3 ! 2004 I I~REBY CERTIFY THAT THE ATTACHED I~ A TRUE COPY OF A RECORD ON FILE IN T~HE DIVISION OF VITAL RECORDS Please Type or Print in Black Im~ellble Ink. Ensure Ali Cople~ St te of Ma~tand e f alth and Mental Hygiene 12-2-53 PA Clifford G. Gontz/Husband 334 fitrohm Road, Shippensbur , PA 17257 Cumberland 17257 ESTATE OF CONNIE D. GONTZ, late of the Township of Southampton, Cumberland County, Pennsylvania, deceased : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY : PENNSYLVANIA : ORPHANS' COURT DIVISION : ESTATE NUMBER 21-04-0848 CERTIFICATION OF NOTICE UNDER RULE 5.6 (a) Name of Decedent: Connie D. Gontz Date of Death: August 16,2004 Will No. 21-04-0848 To the Register: I certify that notice of beneficial interest 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 September 16, 2004: Clifford G. Gontz 334 Strohm Road Shippensburg, PA 17257 Kelly E. Stine 11278 Old Mill Road Shippensburg, PA 17257 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except NONE. September 16, 2004 Name: ~erry A. Weigle, Esquire Address: Weigle & Associates, P.C. 126 East King Street Shippensburg, PA 17257 Telephone: (717) 532-7388 Capacity: Personal Representative X Counsel for Personal Representative ESTATE OF MICHAEL P. CALABRESE, JR. DECEASED TRUST U/VV f/bio Jennifer C. Danko and Christie A. Calabrese: IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS COURT DIVISION NO. 848 OF 2003 AND NOW, this day of _ ,2004, upon consideration of the Petition of Jennifer C. Danko and Christie A. Calabrese for Termination of Trust: IT IS HEREBY ORDERED THAT 1. The Trust established under ITEM Vi(b) of the Last Will and Testament of Michael P. Calabrese, Jr. for the benefit of Jennifer C. Danko and Christie A. Calabrese is hereby terminated. The personal representative of the estate of Michael P. Calabrese, Jr. is hereby directed to make any distribution from the estate otherwise due to the Trust directly to Jennifer C. Danko and Christie A. Calabrese, in equal shares. By the Court: Exhibit A Exhibit B Exhibit C oPYk WEIGLE & ASSOCIATES, RC. Attorneys at Law 126 East King Street Shippensburg, PA 17257 COMMONWEALTH OF PENNSYLVANIA DEPARTMENTOFREVENUE BUREAU OFINDIVIDUAL TAXES DEPT280601 HARRISBURG, PA 17128 O601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT REV 1162 EX(11 96) NO. CD 004581 WEIGLE JERRY A 126 E KING STREET SHIPPENSBURG, PA 17257 ........ fold ESTATE INFORMATION: SSN: 172-46-2709 FILE NUMBER: 21 04-0848 DECEDENT NAME: GONTZ CONNIE D DATE OF PAYMENT: 11/03/2004 POSTMARK DATE: 11/02/2004 COUNTY: CUMBERLAND DATE OF DEATH: 08/16/2004 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $175.00 TOTAL AMOUNT PAID: $175.00 REMARKS: SEAL CHECK# 100 INITIALS: JA RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS OMMONWEALTH OF PENNSYLVANIA DEPAR~vlENT OF REVENUE REV-15OO INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONLY FILE NUMBER 21 04. COUNTY CODE YEAR O848 HARRISBURG, PA 17128-0601 NUMBER DECEDENT~S NAME {LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER r- Gontz, Connie D. 172-46-2709 UJ DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DUPLICATE WITH THE c~ 08-16-2004 12-02-1953 REGISTER OF WILLS uJ ~ ~(~F APPUCABLE) SURVNING SPOUSE'S NAME ( LAST FIRST AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER Gontz, Clifford G. 206-34-8316 UJ 0 X [~1. OriginaIRetum [] 2. Supplementat Return []4. Limited Estate [] 4a. FutumlnterestComp~omise(dateofdeathaffer 12-12.82) [] 6. Oecedent Died Testate IAitach [] 7. Decedent Maintained a Living Trust (Attach copy of V~II) copy of Trust) [] 9. Litigation Proceeds Received [] 10 Spousal Pover~[y Credit (date of death behveen ' 1241-91 and 1-1-95) 'dAME Jerry A. Weigle, Esquire =IRM NAME (If applicable) Weigle & Associates, P.C. rELEPHONE NUMBER 717-532-7388 ] 3, Remainder Return (date of death prior to 12-13-82) 5. Federal EstateTax Return Required 8. Total Number of Safe Deposit Boxes ] 11 .Election to tax under Sec. 9113(A) (Attach Sch O) COMPLETE MAILING ADDRESS 126 East King Street Shippensburg, PA 17257 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sore-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) [] Separate Billing Requested 7. Inter-Vivos Transfers & Miscelraneous Non-Probate Property (Schedule G or L) [] Separate Bilring Requested 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedute H) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) 11. Total Deductions (total Lines 9 & 10) (1) None (2) None (3) None (4) None (5) 28,643.41 (6) None (7) None (9) 17,096.7t (1o) 78.00 12. Net Value of Estate (Line 8 minus Line 11) 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (8) 25,543.41 (11) 17,174.71 (12) 8,368.70 (13) 0.00 (14) 8,368.70 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15.Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116(a)(1.2) 16.Amount of Line 14 taxable at lineal rate 17.Amount of Line 14 taxable at sibling rate 18. Amount of Line 14 taxable at collatera~ rate 19. Tax Due 4,184.35 4,184.35 0.00 0.00 x .00 (15) x .045 (16) x .t2 (17) x .15 (ts) (19) 0.00 188.30 0.00 0.00 188.30 Copyright 2002 form software only The Lackner Group, Inc. Form REV-t500 EX (Rev. 6-00', Decedent's Complete Address: STREET ADDRESS 334 Strohm Road CTY Sh ppensburg ISTATE PA IZIP 17257 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 175.00 9.21 Total Credits (A + B + C) (1) 188.30 (2) 184.21 3. Inferest/Penalty if appricable D, Interest E. Penalty, Total Interest/Penalty (D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is theOVERPAYMENT (4) Check box on Page 1 Line 20 to request a refund 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is theTAX DUE (5) 4.09 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is theBALANCE DUE (5B) 4.0 9 Make Check Payable to: REGISTER OFWILLS, 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. ft 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 I~ YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Uncle[ ~}~_aiti~s of ~edu.w, I declare.that .I hay? examined this · urn. including accompa~lyleg schedules ~ s[atements, and o the best of my knowledge and be el, it s rue, correct and com@iete UeClerat~n o~ preparer otner than tr~e persc~lal rel~esentoflVe is based on ElJl informatlen of which predator has a~y knoWled~le. Hire ADDRESS DATE 334 Strohm Road Ship.ensburg, PA 17257 / ~_ Z~--~]--~ ADDRESS DATE ADDRESS tz- c"cL/ DATE Clifford 126 East King Street Shippensburg, PA 17257 For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [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% [72 P.S. §9116 (a) (1.1) (ii)]. The statutsdoes not exemot 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 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%, 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% [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+ SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONV~cALTH OF pENNSYLVANIA INHERITANCE T,~X RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Gont~, Connie D, 21-04-0848 Include the proceeds of litigation and the date the proceeds were ~ceived by the estate All prope~y Jointly-owned with the right of su~lvomhip must be disclosed on schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 State System of Higher Education - final paycheck, plus unused annual leave, sick 25,543.41 leave, personal days, and holiday time, received 1011512004 ~ TOTAL (Also enter on Line 5, Recapitulation) 25,543.4'1 (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) 24,296.53 3,262.58 501.08 167.03 167.03 978.00 27,659.35 27,659.35 27659.35 57031.60 25,543.41 CHECK NO. 0000120785 8HI~EEBBflI~G 5¥ 33~ 8~OB:~ ~D Annual Leave 330.75000 Sick Leave 1521.58000 Annual Leave Carry 0.00000 Personal Leave 15.00000 Withholding Tax Social Security Tax Medicare Tax Withholding Tax Unemployment Tax Occupation Tax Withholding Tax Federal Federal 4,379.93 1,714.88 3,535.96 401.06 826.96 901.78 26.44 10.00 411.16 2~115.94 10.092:23 27,659.35 27,659.35 BULLETIN BOARD 27,536.49 57,O31.60 57,031.60 29,372.25 29,372.25 29,372.25 SERS (EMPL AFSCME MEM 1,835.76 0.00 440.52 0.00 2,276.28 Fed W/H Status is Single Residence :Southampton Work Tax Area :Shippensburg DETACH ALONG THIS PERFORATION OF PAY EXACTLY ~RORMR~ SHIPPENSBURG PA 17257 * *' TWENTY-FIVE THOUSAND FIVE HUNDRED'FORTY-THREE USD and FORTY-ONE Cents ISSUE DATE: 10/1512004 SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Gontz, Connie D. 21-04-0848 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 5. 6. 7. See continuation schedule(s) attached ADMINISTRATIVE COSTS: Personal Representative's Commissions Social Security Number(s) / EIN Number of Personal Representative(s): Street Address City State Zip Year(s) Commission paid See continuation schedule(s) attached Attorney's Fees Weigle & Associates, P.C. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Clifford G. Gontz street Address 334 Strohm Road City Shippensburg State PA Zip 17257 Relationship of Claimant to Decedent Spouse Probate Fees See continuation schedule(s) attached Accountant's Fees Tax Return Preparer's Fees Other Administrative Costs TOTAL (Also enter on line 9, Recapitulation) 10,438.54 1,277.00 1,350.00 3,500.00 ; 79.00 452.17 17,096.71 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-tS02 EX+ (6-98) COM M(3h~J~.ALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Gon~,Connie D. SCHEDULE H-A FUNERAL EXPENSES continued FILE NUMBER 21-04-0848 ITEM NUMBER DESCRIPTION 1 2 3 4 Cleversburg Cemetery - grave opening Cleveraburg Cemetery - lot Fogelsanger-Bricker Funeral Home Wagoner's Memorials Subtotal AMOUNT 325.00 600.00 7,763.54 1,750.00 10,438.54 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-A (Rev. 6-98) Rev-1502 EX+ (6-98) SCHEDULE H-Bt PERSONAL REPRESENTATIVE'S COMMISSIONS continued COMMONWEALTH OF PENNS'fl-VANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Gon~, Connie D. 21-04-0848 ITEM NUMBER DESCRIPTION AMOUNT 1 1,277.00 Clifford G. Gontz -Administrator's Commission 334 Strohm Road~ Shippensburg, PA 17257 SS # 205-34-8316 Year Commission Paid - 2004 Subtotal 1,277.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-B1 (Rev. 6-98) Rev-1502 EX+ (6-98) SCHEDULE H-B4 PROBATE FEES continued ESTATE OF FILE NUMBER Gontz, Connie D. 21-04-0848 ITEM NUMBER DESCRIPTION AMOUNT I Register of Wills, Cumberland Coun~ - Lettem of Administration and Short 79.00 Certificates Subtotal 79.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H-B4 (Rev. 6-98) Rev-lEO2 EX+ (6-98) SCHEDULE H-B7 OTHER ADMINISTRATIVE COSTS continued COMMONWEAL3~-~ OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Gont~, Connie D. 21-04-0848 ITEM NUMBER DESCRIPTION AMOUNT 1 2 3 4 5 6 7 Cumberland Law Journal - advertising Letters of Administration Linda K. Klein - notary fee News Chronicle - advertising Letters of Adminstration Orrstown Bank - estate checks Register of Wills, Cumberland County - filing PA Inheritance Tax Return Register of Wills, Cumberland County - filing Family Settlement Agreement Washington County Hospital - medical records 75.00 9.00 84.50 11.60 15.00 75.00 182.07 Subtotal 452.17 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H~B7 (Rev. 6-98) Rev-1512 EX+ (6-98) COMMONV~J4.TH OF PENNSYLVANIa, INHERITANCE TAX RETURN RESIDENT DECE{3ENT ESTATE OF Gontz, Connie D. SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS FILE NUMBER 21-04-0848 ITEM NUMBER 1 2 DESCRIPTION Chambersburg Hospital - 08113104 service Chambemburg Imaging Associates - 08/13/04 service VALUE AT DATE OF DEATH 50.00 28,00 TOTAL (Also enter on Line 10, Recapitulation) 78.00 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-t500 Schedule I (Rev. 6-98) REV-IS13 EX+ (g-O0) ~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER Gontz, Connie D. 21-04-0848 NAME AND ADDRESS OF SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S) RECEIVING PROPERTY 0Nords) ($$$) RELATIONSHIP TO DECEDENT DO Not Ll~t Tmsteels} TAXABLE DISTRIBUTIONS [include outright spousal distributions and transfers under Sec. ~116(a)(1.2)] Kelly E. Stine Daughter 1/2 4,184.35 11278 Old Mill Road Shippensburg, PA 17257 Clifford G. Gontz Spouse 112 4,184.35 334 Strohm Road Shippensburg, PA 17257 Total 8,368.70 Enter dollar amounts for distributions shown above on lines NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 5 through 18, as appropriate, on Rev 1500 cover sheet B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEE'I Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-I$00 Schedule J (Rev. 6-98) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT 280601 HARRISBURG, PA 17128-0001 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT REV 1162 EX(11-96) NO. CD 004760 WEIGLE JERRY A 126 E KING STREET SHIPPENSBURG, PA 17257 ........ fold ESTATE INFORMATION: SSN: 172-46-2709 FILE NUMBER: 2104-0848 DECEDENT NAME: GONTZ CONNIE D 12/22/2004 DATE OF PAYMENT: POSTMARK DATE: 1 2/22/2004 COUNTY: CUMBERLAND DATE OF DEATH: 08/16/2004 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 $4.09 TOTAL AMOUNT PAID: $4.09 REMARKS: SEAL CHECK#107 INITIALS: JA RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE '*' BUREAU OF INDIVIDUAL'lAXES INHERITANCE TAX DIVISION PO BOX Z80601 HARRISBURG PA 171Z8-0601 NOTICE OF INHERITANCE TAX 'APPRAISEMENT, ALLOWANCE OR DISALLOWANCE , OF DEDUCTIONS AND ASSESSMENT OF TAX REV-1547 EX AFP (12-D4) i n I i:.~ t c' 10 11'40 CLERK O. R... DJ I nd'C: iJ'lrt'~-J''4 \j JERRY A ~Gt2EC)ESQ' WEIGLE & ASSOCS 126 EKING ST SHIPPENSBURG PA 17257 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 03-21-2005 GONTZ 08-16-2004 21 04-0848 CUMBERLAND 101 Allount Rellitted CONNIE D MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ RE.V:r!~""EXAFp.rBl---lJ~".N6".icE.OF.iNHEj(I.fiiicE.;--AX.APPRA.fsEMEAT~..A[tOWANCE.OR................- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF GONTZ CONNIE D FILE NO. 21 04-0848 ACN 101 DATE 03-21-2005 TAX RETURN WAS: (X) ACCEPTED AS FILED ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Stock/Partnership Interest (Schedule C) 4. Mortgages/Notes Receivable (Schedule D) S. Cash/Bank Deposits/Hisc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) S. Total Assets ll) (2) (3) (4) (S) (6) (n .00 .00 .00 .00 25,543.41 .00 .00 (S) NOTE: To insure proper credit to your account, sublJi t the upper portion of this forll with your tax paYllent. 25,543.41 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adll. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governllental Bequestsj Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax (9) 1l0} 17,096.71 78.00 llU 112} (13) (14) 17.174 71 8,368.70 .00 8,368.70 I~ an assessment was issued previOUSly, lines 14, 15 and/or 16, 17, 18 and 19 will re~lect ~igures that include the total o~ ALL returns assessed to date. ASSESSMENT OF TAX: lS. Allount of Line 14 at Spousal rate (lS) 16. Allount of Line 14 taxable at Lineal/Class A rate (16) 17. Allount of Line 14 at Sibling rate (17) lS. Allount of Line 14 taxable at Collateral/Class B rate (lS) 19. Principal Tax Due TAX CR I NOTE: 4,184.35 X 4,184.35 X .00x .00 X 00 = 045 = 12 = 15 = (19)= .00 188.30 .00 .00 188.30 DATE 11-02-2004 12-22-2004 NUMBER CD004581 CD004760 + INTEREST/PEN PAID (-) 9.21 .00 AMOUNT PAID 175.00 4.09 ~ TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE 188.30 .00 .00 .00 . IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.} - f\ .~~, - /"" . f";! !~ \/4, ~ ~, )'/ H '~"'~1 -.--.- 111m ..., =>Xz ffi~g m;i!! a:=>~ ;:: ~e~ :( 54 a. I~~i~ ~~~!; t~ffi\ii o~i~~ flD- ---. ~ ~ ~ "- '" '" '" -o~ ~~ ~ ~ ~c1l V-o '5 9 ~o-li\ . '.., ~~i\::] "Q -..-.z ,.. ~~"'- g \ ~.\~~'l ~ . ~.~~~ ;r. - -= -: -. 1 =E - 1 - -: :E -: -= - E :] - E - li@ 8 z ~ (')0 c ::r:z ill ~!:( :i! ~c Iii m o~ ~ '-I ; tP::r: 5- (')00 ,,~ 'ii ~< ... . m 2 :'05 ~ ~"1:J -1m !l: ....- i "TI i ~ c :. z ~ ;I: '" < c 0 ~ c COHHONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. Z8D6Dl HARRISBURG~ PA 171Z8-D6DI .~"')I'.. ~. --",'~,'--' INFORMATION NOTICE AND TAXPAYER RESPONSE FILE ACN DATE NO. 21 04-0848 04147423 12-20-2004 REV-15UEXil'P-(1J9<..81J 'U-. T) r EST. OF CONNIE D GONTZ S. S. NO. 172-46-2709 DATE OF DEATH 08-16-2004 COUNTY CUMBERLAND TYPE OF ACCOUNT IX] SAVINGS o CHECKING o TRUST o CERTIF. ( r: c. KELLY E STINE 11278 OLD MILL RD SHIPPENSBURG PA 17257 REMIT PAYMENT AND FORMS TO, REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 ORRSTOWN BANK has provided the Departllent with the information listed below which has bean used in calculating the potantial tax dua. Their records indicata that at the death of the abova decedent~ you wera a joint owner/beneficiary of this account. If yoU feel this inforllation is incorrect~ pleasa obtain written correction frOIl the financial institution~ attach a copy to this form and return it to tha above addrass. This account is taxable in accordance with the Inheritance Tax Laws of the COllmonwealth of Pennsylvania. Questions .ay be answerad by calling (717) 787-83Z7. COMPLETE PART 1 BELOW . . . SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 719064 Oat. 03-15-1988 Established Account Balance Percent Taxable Amount Subject to Tax Rate Potential Tax Due x 17,069.16 50.000 8,534.58 .15 1,280.19 TAXPAYER RESPONSE To insure proper cradit to your account~ two CZ) copies of this notice IIUSt accompany your payment to the Ragister of Wills. Make check payable to: nRagister of Wil1s~ Agent". Tax x NOTE: If tax paYllents ar_~ made Withlr!..,}hree (3) months of the dacedsnt's data ofd.ath~ YOU may deduct a 5X discouht'of the ~ due. Any inheritanca tax due will become ~8~inquent nine (9) months aftar the date of daath. PART [!] abova inforllation and tax due is corract. You lIIay choose to remit paYllent to the Register of Wills with two copies of thls notice"to obta:in a discount or avoid interest~ or you lIay chack box nA" and return this notice fo the Rs9fstar of Wills and an official assessment will be issuad by the PA Dapartment of Revenue. [CHECK ] ONE BLOCK ONLY '.::) B. 0 The above asset has been or will be reported and tax paid with the Pennsylvania Inheritanc';-;:ax to be filad by the dacedant.s raprasentative. return c. 0 Tha above inforllation is incorrect and/or debts and deductions were paid by you. You IIUSt co.pleta PART ~ and/or PART ~ below. If you indicate a different tax rate~ please state your relationship to decedent: PART ~ TAX RETURN - COMPUTATION OF TAX ON LINF. 1. Date ~~tabli~hed 1 2. Account Balance 2 3. Percent Taxable 3 X 4. Amount Subject to Tax 4 5. Debts and Deductions 5 6. Amount Taxable 6 7. Tax Rate 7 X 8. Tax Due 8 JOINT/TRUST ACCOUNTS PART [!j DATE PAID DEBTS AND DEDUCTIONS CLAIMED 4<Jr> Ii< ./1. '+-oil ^ I,;) )<;()_ /'1 I TOTAL (Enter on Line 5 of Tax Computation) $ .1. :),IQ PAYEE DESCRIPTION AMOUNT PAID p.rjury~ I declare that the facts I y knowledge and belief. have reported above are true~ correct HOME (/17) S:?d-37dl? WORK ( ) ELEPHO E N MHER and TAXPAY DATE GENERAL INFORMATION 1. FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT with applicable interest based on inforllation submitted by the financial institution. z. Inheritance tax becoIIss delinquent nine .onths after the decedant's date of dssth. 3. A joint account 1s taxable Bven though the decedent's nalle was added as a mattar of convenience. 4. Accounts [including those held between husband and wife) which the decedent put in joint names within on8 year prior to death arB fully taxable as transfars. 5. Accounts established jointly between husband and wife lIorB than one year prior to death are not taxable. 6. Accounts held by a decedent "in trust for" another or others are taxable fully. REPORTING INSTRUCTIONS - PART 1 TAXPAYER RESPONSE 1. BLOCK A _ If the inforlllation and cOlllputation in the notice are correct and deductions are not being clabed, place an "X" in block "A" of Part 1 of the "Taxpayer Response" section. Sign two copies and subllit tham with your check for the allount of tax to the Register of Wills of the county indicated. The PA Department of Revenue will issue an official aSSBsSllent (Form REV-1548 EX) upon receipt of the return from the Register of Wills. 2. BLOCK B _ If the asset specified on this notice has been or will be reported and tax paid with the Pennsylvania Inheritance Tax Return filed by the decedent's representative, place an "X" in block "B" of Part 1 of the "Taxpayer Response" section. Sign one COpy and return to the PA Department of Revenue, Bureau of Individual Taxes, Dept 280601, Harrisburg, PA 17128-06Dl in the envelope provided. 3. BLOCK C _ If the notica inforllation is incorract and/or deductions are being clai.ad, check block "C" and cOllplete Parts 2 and 3 according to the instructions below. Sign two copies and subllit thell with your check for the allount of tax payable to the Register of Mills of the county indicated. The PA Departllent of Revenue will issue an official assessllent (Form REV-1548 EX) upon receipt of the return frail the Register of Wills. TAX RETURN - PART 2 - TAX COMPUTATION LINE 1. Enter NOTE: the date the account originally was established or titled in the .anner existing at date of death. For a decedent dying after 12/12/82: Accounts which the decedent put in joint nalles within one (1) year of death are taxable fully as transfers. However, there is an exclusion not to exceed $3,000 per transferee regardless of the value of the account or the nUllber of accounts held. If a double asterisk (MW) appears before your first nalle in the address portion of this notice, the $3,000 exclusion already has been deducted frail the account balance as reported by the financial institution. 2. Enter the total balance of the account including interest accrued to the data of death. 3. The percent of the account that is taxable for each survivor is determined as follows: A. The percent taxable for joint assets established more than one year prior to the decedent's death: 1 DIVIDED BY TOTAL NUMBER OF JOINT OWNERS Example: A joint asset registered DIVIDED BY TOTAL NUMBER OF X 100 PERCENT TAXABLE SURVIVING JOINT OWNERS in the name of the decedent and two other persons. B. The percent taxable for assets created within one year of the decedant's death or accounts owned by the decedent but held in trust for another individual(s) (trust beneficiaries): 1 DIVIDED BY 3 (JOINT OWNERS) DIVIDED BY 2 (SURVIVORS) - .161 X 100 16.7X (TAXABLE FOR EACH SURVIVOR) 1 DIVIDED BY TOTAL NUMBER OF SURVIVING JOINT OWNERS DR TRUST BENEFICIARIES X 100 PERCENT TAXABLE Example: Joint account registered the decedant. 1 DIVIDED BY 2 (SURVIVORS) = .50 in the name of the decedent and two other persons and established within one year of death by X 100 SOX (TAXABLE FOR EACH SURVIVOR) 4. The allount subject to tax (line 4) is determined by multiplying the account balance (line 2) by the percent taxable (line 3). 5. Enter the total of the debts and deductions listed in Part 3. 6. The Hount taxable (line 6) is deterllined by subtracting the debts and deductions (line 5) froll the amount subjact to tax (line 4). 7. Enter the appropriate tax rate (line 7) as daterllined below. death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is ox. The lineal class of heirs includes grandparents, parents, children, and lineal descendents. "Children" includes natural children whether or not they have been adopted by others, adopted children and step children. "Lineal descendents" includes all children of the natural parents and their descendents, whether or not they have bean adopted by others, adopted descendents and their descendants and step-descendants. "Siblings" are defined as individuals who have at least one parent in COllllon with the decedent, whether by blood or adoption. The "Collateral" class of heirs includes all other beneficiaries. Date of Death Spouse Lineal Sibling Collateral 07101/94 to 12/31/~4 3Y. 6Y. 157- 157- 01/01/95 to 06/30/00 OY. 6Y. 15Y. 15Y. 07101100 to present OY. 4.57.- 12Y. 15Y. wThe tax rate Imposed on the net value of transfers from a deceased chIld twenty-one years of age or y ounger at CLAIMED DEDUCTIONS - PART 3 DEBTS AND DEDUCTIONS CLAIMED Allowable debts and deductions are deterlllned as follows: A. You legally are responsible for payment, or tha estate SUbject to administration by a personal representative is insufficient to pay the deductible itams. B. You actually paid the debts after death of the decedent and can furnish proof of pay.ent. C. Debts being clai.ed lIust be itellized fullY in Part 3. If additional space is needed, use plain paper 8 112" x 11". Proof of paYllent .ay be requested by the PA Depart.ent of Revenue. 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 STINE KELLY E. 11278 OLD MILL RD SHIPPENSBURG, PA 17257 --------Iold EST A TE INFORMATION: SSN: 172-46-2709 FILE NUMBER: 2104-0848 DECEDENT NAME: GONTZ CONNIE D DATE OF PAYMENT: 04/26/2005 POSTMARK DATE: 04/20/2005 COUNTY: CUMBERLAND DATE OF DEATH: 08/16/2004 NO. CD 005246 ACN ASSESSMENT CONTROL NUMBER AMOUNT 04147423 I $1,280.19 I I I I I I I I TOTAL AMOUNT PAID: REMARKS: CHECK# 1129 SEAL INITIALS: JA RECEIVED BY: REGISTER OF WILLS $1,280.19 GLENDA FARNER STRASBAUGH REGISTER OF WILLS ESTATE OF CONNIE D. GONTZ File No. 21-04-0848 FAMILY SETTLEMENT AGREEMENT TIllS AGREEMENT m,d, ilii, ~ d', of ~ · ,2065, BETWEEN: CLIFFORD G. GaNTZ and KELLY E. ST E, being the heirs-~t. law of Connie D. Gontz, late of the Township of Southampton, Cumberland CountY; Pennsylvania, AND CLIFFORD G. GaNTZ, Administrator of the Estate of Connie D. Gontz, deceased. WHEREAS, Connie D. Gontz died August 16,2004, intestate; and WHEREAS, Letters of Administration were granted to Clifford G. Gontz on September 15,2004, by the Register of Wills of Cumberland County, Pennsylvania; and WHEREAS, all assets of the late Connie D. Gontz have been liquidated or distributed and all her debts paid in full, and further the period of four months having been terminated since the first advertisement of the issuance of Letters to the said Administrator, the said parties hereto desire to waive the duty of the Administrator to file a First and Final Account with Proposed Schedule of Distribution for purposes of confirmation by the Court of Common Pleas of Cumberland County, Orphan's Court Division, AND FURTHER desire that a Family Settlement Agreement be executed, which Family Settlement Agreement will be duly recorded among the deed records in and for Cumberland County. \)'- WEIGLE & ASSOCIATES. P.c. - ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPENSBVRG, PA 17257-1397 NOW, THEREFORE, WITNESSETH, that the parties hereto, in consideration of the premises above stated, and of the Accounting and Proposed Schedule of Distribution attached hereto and made a part hereof, and the receipt of their distributive shares as therein shown, do mutually bind themselves to the said Distribution and Accounting as set forth and further mutually release Clifford G. Gontz, Administrator, from all claims and demands whatsoever arising out of settlement of the Estate of Connie D. Gontz. The parties hereto do further agree that should any liability come due to the estate of the said decedent after the signing of this agreement, they do hereby covenant and agree with the aforesaid personal representative that they will contribute pro rata their share of the estate to satisfy any and all claims, demands, suits, or causes of action which may be successfully prosecuted against the said estate or the aforesaid personal representative after the signing, sealing and delivery of this family settlement agreement and final release. IN WITNESS WHEREOF, the parties have hereunto set their hands and seals the day and year first above written. WITNESS: (SEAL) (SEAL) WEIGLE & ASSOCIATES, P.C. - ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPENSBURG, PA 17257-1397 COMMONWEALTH OF PENNSYLVANIA SS. COUNTY OF CUMBERLAND On this the IX<Ji;;. day of ~ ' 2005, before me, a Notary Public in and for said County and State, the undersigned officer, personally appeared CLIFFORD G. GONTZ and KELLY E. STINE, known to me (or satisfactorily proven) to be the persons whose names are subscribed to the within instrument, and acknowledged that they executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official seal. n AL) NOTARIAL SEAL Jerry A. Weigle, Notary Public Shippensburg, PA Cumbe~and County My Commission Expires October 7, 2006 WEIGLE & ASSOCIATES, P.c. - ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPENSBURG, PA 17257-1397 ADMINISTRATOR'S ACCOUNT FIRST AND FINAL ACCOUNT OF CLIFFORD G. GONTZ, ADMINISTRATOR FOR ESTATE OF CONNIE D. GONTZ, DECEASED Date of Death: Date of Administrator's Appointment: Dates of Advertisement of Letters: News Chronicle Cumberland Law Journal Accounting for the Period: August 16,2004 September 15,2004 September 24, October I, 8, 2004 October I, 8, 15,2004 August 16,2004, to AprilS, 2005 Purpose of Account: Clifford G. Gontz, Administrator, offers this account to acquaint interested parties with the transactions that have occurred during his administration. The account also indicates the proposed distribution of the estate. It is important that the account be carefully examined. Requests for additional information or questions or objections can be discussed with: Jerry A. Weigle, Esquire Weigle & Associates, P.C. 126 East King Street Shippensburg, P A 17257 717-532-7388 WEIGLE & ASSOCIATES, P.c. - ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPENSBURG, PA 17257-1397 SUMMARY OF ACCOUNT . . Estate of Connie D. Gontz, Deceased For the period of AUQust 16. 2004 throuQh April 5. 2005 Proposed Distributions to Beneficiaries PRINCIPAL Receipts: This Account Net Gain (or Loss) on Sales or Other Dispositions Less Disbursements: Debts of Decedent Funeral Expenses Administration Expenses Federal and State Taxes Commissions Fees Family Exemption Balance Before Distributions Transfer to (from) Principal Distributions to Beneficiaries Principal Balance on Hand For Information: Investments Made Changes in Investment Holdings INCOME Receipts This Account Net Gain (or Loss) on Sales or Other Dispositions Less Disbursements Balance Before Distributions Transfer to (from) Income Distributions to Beneficiaries Income Balance on Hand For Information: Investments Made Changes in Investment Holdings COMBINED BALANCE ON HAND PaQe 5 1 2 2 2 2 3 3 3 4 Current Value 2,710.61 78.00 10,438.54 6,010.17 179.09 1,277 .00 1,350.00 3,500.00 Fiduciary Acquisition Value 2,710.61 25,543.41 0.00 25,543.41 22,832.80 2,710.61 0.00 0.00 2,710.61 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2,710.61 SCHEDULE A RECEIPTS OF PRINCIPAL 08/16/2004 Cash State System of Higher Education - final paycheck, plus unused annual leave, sick leave, personal days, and holiday time, received 10/15/2004 25.543.41 Total Receipts of Principal 1 Fiduciary Acquisition Value 25.543.41 25.543.41 SCHEDULE C DISBURSEMENTS OF PRINCIPAL Debts of Decedent 10/27/2004 Chambersburg Hospital - 08/13/04 service 50.00 11/02/2004 Chambersburg Imaging Associates - 08/13/04 28.00 service Total Debts of Decedent 78.00 Funeral Expenses 10/27/2004 Fogelsanger-Bricker Funeral Home 7.763.54 10/27/2004 Cleversburg Cemetery - grave opening 325.00 10/27/2004 Cleversburg Cemetery - lot 600.00 11/0212004 Wagoner's Memorials 1.750.00 Total Funeral Expenses 10,438.54 Miscellaneous Administration Expenses 10/27/2004 Register of Wills, Cumberland County - Letters 79.00 of Administration and Short Certificates 10/27/2004 Cumberland Law Journal - advertising Letters of 75.00 Administration 10/27/2004 Washington County Hospital - medical records 182.07 11/02/2004 Orrstown Bank - estate checks 11.60 11/09/2004 News Chronicle - advertising Letters of 84.50 Adminstration 12/09/2004 Register of Wills, Cumberland County - filing PA 15.00 Inheritance Tax Return 12/09/2004 Linda K. Klein - notary fee 9.00 02/22/2005 Clifford G. Gontz - reimbursement for additional 5.479.00 2004 federal income tax owed on estate funds paid by Shippensburg University 04/05/2005 Register of Wills, Cumberland County - filing 75.00 Family Settlement Agreement Total Miscellaneous Administrative Expenses 6,010.17 2 SCHEDULE C DISBURSEMENTS OF PRINCIPAL Continued Taxes 11/02/2004 Register of Wills, Cumberland County - 175.00 Pennsylvania Inheritance Tax payment at discount 12/09/2004 Register of Wills, Cumberland County - 4.09 Pennsylvania Inheritance Tax Total Taxes 179.09 Commissions 12/09/2004 Clifford G. Gontz - Administrator's Commission 1.277.00 334 Strohm Road, Shippensburg, PA 17257 SS # 205-34-8316 Year Commission Paid - 2004 Total Commissions 1.277.00 Fees 12/09/2004 Weigle & Associates, P.C. - Attorney Fee 1.350.00 Total Fees 1.350.00 Familv Exemption 12/09/2004 Clifford G. Gontz - Family Exemption 3.500.00 334 Strohm Road Shippensburg, PA 17257 Spouse Total Familv Exemption 3.500.00 TOTAL DISBURSEMENTS OF PRINCIPAL 22.832.80 3 # Units PRINCIPAL BALANCE ON HAND Description Cash Orrstown Bank Estate Checking Acc Total Cash 4 Current Value 04/05/2005 or as Noted 2.710.61 2.710.61 2.710.61 Fiduciary Acquisition Value 2.710.61 2.710.61 2.710.61 PROPOSED DISTRIBUTIONS TO BENEFICIARIES Current Value Fiduciary 04/05/2005 Acquisition or as noted Value TO: Clifford G. Gontz 1/2 of Estate - Cash 1.355.30 1.355.30 1.355.30 1.355.30 TO: Kellv E. Stine 1/2 of Estate - Cash 1.355.31 1.355.31 1.355.31 1.355.31 Total 2.710.61 2.710.61 5 CLIFFORD G. GaNTZ, Administrator of the Estate of Connie D. Gontz, deceased, hereby declares under oath (penalties of perjury) that he has fully and faithfully discharged the duties of his office; that the foregoing First and Final Account is true and correct and fully discloses all significant transactions occurring during the accounting period; that all known claims against the estate have been paid in full; that, to his knowledge, there are no claims now outstanding against the estate; and that all taxes presently due from the estate have been paid. Subscribed and sworn to by CLIFFQ!w-. G. GON~e me this ~day of , 2005. NOTARIAL SEAL . Jerry A. Weigle, Notary Public Shlppensburg, PA Cumberland County My CommIssIon Expires October 7, 2006 WEIGLE & ASSOCIATES, P.c. - ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPENSBURG, PA 17257-1397 REGISTER OF WILLS, CUMBERLAND COUNTY STATUS REPORT UNDER RULE 6.12 Name of Decedent: Connie D. Gontz Date of Death: 08/16/2004 Will No.: Admin. No.: 21-04-0848 Pursuant to Rule 6.12 of the Supreme Court Orphans' Comi 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: Yes IiI No 0 2. lfthe answer is No, state when the. personal representative reasonably believes that the administration will be complete: 3. If the answer to No.1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes No fKl 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? Yes lKJ No 0 c. Copies of receipts, releases, joinders and approval of formal or informal accounts may be filed with the Clerk oftl?-e Orph ' C and may be attached to t port. Date: ~/ff;lcs Jerry A. Weigle, Esquire Name WEIGLE & ASSOCIATES, P.C. 126 East King Street Shippensburg. PA 17257 Address "~\ 717-532-7388 Telephone No. Capacity: n Personal Reoresentative ill Counsel foy.personal representative j BUREAU OF INDIVIDUAt-TAXES INHERITANCE taX DIVISION-',". PO BOX 280601 HARRISBURG PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEKEHT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS, AND ASSESSIIEHT OF TAX ON .JOIHTL Y HELD OR TRUST ASSETS *' REv-l54a EX AFP (D3-05] I .~ ,..; 51 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY SSN/DC ACN 06-13-2005 GONTZ 08-16-2004 21 04-0848 CUMBERLAND 172-46-2709 04147423 Amount R.itt.d CONNIE D CU~,,;:- KELLY E STINE 11278 OLD MILL RD SHIPPENSBURG PA 17257 MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ A~-:rI'1ri!I:~~.~a~1nI'.................................................................................... NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS, AND ASSESSMENT OF TAX ON JOINTLY HELD OR TRUST ASSETS DATE 06-13-2005 ESTATE OF GONTZ CONNIE D DATE OF DEATH 08-16-2004 COUNTY CUMBERLAND FILE NO. 21 04-0848 TAX RETURN WAS: S.S/D.C. NO. 172-46-2709 (X) ACCEPTED AS FILED () CHANGED JOINT OR TRUST ASSET INFORMATION ACN 04147423 FINANCIAL INSTITUTION: ORRSTOWN BANK ACCOUNT NO. 719064 TYPE OF ACCOUNT: (lO SAVINGS ( ) CHECKING ( ) TRUST ( ) TIME CERTIFICATE DATE ESTABLISHED 03-15-1988 Account Balance Percent Taxable X Amount Subject to Tax Debts and Deductions Taxeble Amount Tax Rate X Tax Due 17 , 069.16 0.500 8,534.58 .00 8,534.58 .15 1,280.19 NOTE: TO INSURE PROPER CREDIT TO YOUR ACCOUNT, SUBMIT THE UPPER PORTION OF THIS NOTICE WITH YOUR TAX PAVMENT TO THE REGISTER OF WILLS AT THE ABOVE ADDRESS. MAKE CHECK OR MONEY ORDER PAVABLE TO: "REGISTER OF WILLS, AGENT." TAX CREDITS: PAVMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 04-20-2005 CD005246 ' .00 1,280.19 TOTAL TAX CREDIT 1,280.19 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 . IF PAID AFTER THIS DATE, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. . ( IF TOTAL DUE IS LESS THAN Sl, 110 PA YKEHT IS REllUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" ( CRI, YOU KAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FOHN FOR INSTRUCTIONS. I Q ~ 'f-.