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Home My WebLink About04-0861REGISTER OF WILLS CUMBERLAND COUNTY, PENNSYLVANIA PETITION FOR GF NT OF LETTERS Estate of ETHEL A. CLIMENHAGA No. 21-04- also known as JOHN Z. MARTIN Petitioner(s), who is/are 18 years of age or older, apply(les) for: , Deceased Social Security No. 567-46-8747 (COMPLETE "A" OR "B" BELOW:) ] A. Probate and Grant of Letters and aver that Petitioner(s) is/are the execut OR Decedent, dated 11/11/96 and codicil(s) dated named in the Last Will of the Except as follows, Decedent did not mar~, 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 incapacitated: B. Grant of Letters of Administration (c.t.a., d.b.n.c.t.a.: pandente lite, durante absentia; durante minoritate) Petitioner(s) after a proper search has/have ascertained the Decedent left no Will and w~ived by. the folio,,,~.,,, (if any) and heirs: .~. spouse Name Relationship i:' ~esidence , (COMPLETE IN ALL CASES:) Attach additional sheets if necessary. Decedent was domiciled at death in CUMBERLAND County, Pennsylvania, with his/her last family or principal residence at MESSIAH VILLAGE, 100 MT. ALLEN DR.~ UPPER ALLEN TWP., MECHANICSBURG, PA (list street, number and municipality) Decedent, then 92 . years of age, died SEPTEMBER ~7,2004 , at MESSIAH VILLAGE, (Location) Decedent at death owRed property with estimated values as follows: (if dom~'~iled in PA) Air personal property ......................................... $ (if not domiciled in PA) Personal property in Pennsylvania .................... $ (If n~ domiciled in PA) Personal property in County .............................. $ Value of rsal estate in Pennsylvania ............................................... .~ ............................... $ Total ..................................................................................................................... Real Estate 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 appropdata form to the undersigned: Signature Typed or printed name and residence JOHN Z. MARTIN 926 LARCH LOOP~ MECHANICSBURG~ PA 17055 RW-7 Oath of Personal Representative Commonwealth of Pennsylvania County of CUMBERLAND The Petitioner(s) above-named swear(s) and 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 representative(s) of the Decedent, Petitioner(s) will well and truly administer the estate according to law. Sworn to and affirmed and subscribed JOHN Z. MARTIN before methi,~ ~ ;3t,5~. dayof (/~...~v "~ SEPTEMBER 2004 ,~ ' ~ ~ DECREE OF REGISTER Estate of ETHEL A. CLIMENHAGA Deceased No. 21-04- ~J also known as Social Security No: 567-46-8747 Date of Death: AND NOW, __ , in consideration of the Petition on the reverse side hereon, satisfactory proof having been presented before me, IT IS DECREED that Letters Q Testamentary r-i of Administration (c.t.a., d.b.n.c.t.; pendente kite; durante absentia; durante minoritate) are hereby granted to in the above estate and that the instrument(s), if any, dated described in the Petition be admitted to probate and filed of record as the last Will of Decedent. FEES Letters .................................... Short Certificate(s) ............... Renunciation .......................... Affidavit ( ) ....................... Extra Pages ( ) .............. Codicil ................................. JCP Fee ................................. Inventory & Tax Forms ............. Other ...................................... TOTAL ............................. Attorney: GERALD J. BRINSER I.D. No: 09655 Address: 6 E. MAIN STREET, P.O. BOX 323 PALMYRA PA 17078 Telephone: 717838-6348 DATE FILED: q 'c>~,~ -- ~,~..00~ RW-7A his 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 fbrwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate thiS copy by photostat or photograph. Fee for this certificate. $2.00 P 0684148 '~No. ITEM # Iq Local Registl~g~Ltl.]2t& SEP 0 8 200~ Date CERTIFICATE OF DEATH .tBus~ass ~duc. Teacher .~ Education I Y#n ~FI ..... WILL OF ~ ETHEL A. CLIMENHAGA ' ~ I, ETHEL A. CLIMENHAGA, currently of Upper Allen Township, County, Pennsylvania, realizing the uncertainty of this life, but with confidence i~3od and trust in His Son, my Lord and Savior, Jesus Christ, who died for my sins upon the cross and rose again m redeem me and give me eternal life, do hereby make, publish and declare this to be my Last Will and Testament, hereby revoking any and all prior Wills and Codicils made by me. I. I direct that all my just debts and funeral expenses be paid from the assets of my estate as soon as practicable after my demise. II. I direct that all estate and inheritance taxes that may be assessed in consequence of my death, shall be paid out of the principal of my general estate to the same effect as if said taxes were expenses of administration and all property includable in my taxable estate whether or not passing under this Will shall be free and clear thereof. III. I bequeath unto my sister, Velma Heisey, any tangible personal property which she may desire. The balance of my tangible personal property I bequeath unto Messiah Village, Mechanicsburg, Pennsylvania, to be used as it sees best. IV. All the rest, residue and remainder of my estate, of whatever nature and wherever situate, including property over which I hold a power of appointment, I devise and bequeath as follows: A. Ten percent (10%) unto Western Christian, Claremont, California, to be used as it sees best; B. Ten percent (10%) unto Upland Brethren In Christ Church, Upland, California, to be used as it sees best; C. Ten percent (10%) unto Messiah Village, Pennsylvania, to be used in its Endowment Fund; Mechanicsburg, D. Ten percent (10%) to be divided equally among my brothers and sisters who survive me; E. Twenty percent (20%) unto Brethren In Christ World Missions, Grantham, Pennsylvania, to be used as it sees best; F. Twenty percent (20%) unto Brethren In Christ Cooperative Ministries, Grantham, Pennsylvania, to be used as it sees best; G. Twenty percent (20%) unto The Jacob Engle Foundation, Inc., Grantham, Pennsylvania, to be used as it sees best. V. I appoint John Z. Martin Executor of this my Will. In the event that he fails to qualify or ceases to act as Executor, I appoint Gerald J. Brinser, Esquire, Executor of this my Will. VI. I direct that no bond be required of my fiduciary for the faithful performance of his duties in any jurisdiction. IN WITNESS WHEREOF, I, ETHEL A. CLIMENHAGA, herewith set my hand to this my Last Will, typewhtten on two (2) sheets of paper including the attestation clause and signatures of witnesses, this 5th day of November, 1996. THEL A. CLIMENHAGA d Signed by ETHEL A. CLIMENHAGA, by her declared to be her Will in our presence, who have hereunto subscribed our names as witnesses in her presence and at her request, this 5th d,ay of November,/996. -~~~ residingat ~.~/~. ~ ~¢~[~'-- residing at ~tr~ ~ -2- COMMONWEALTH OF PENNSYLVANIA COUNTY OF ~ WE, ETHEL A. CLIMENHAGA, GERALD J. BRINSER and ¢~,,~,~r~,~,e , the testatrix and the witnesses, respectively, whose names are signed to the attached or foregoing instrument, being first duly affirmed, do hereby declare to the undersigned authority that the testatrix signed and executed the instrument as her Last Will and that she signed willingly (or willingly directed another to sign for her), and that she executed it as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and heating of the testatrix, signed the Will as witnesses and that to the best of our knowledge the testatrix was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. ETHEL A. CLIMENHAGA ~ WITNESS "'- Subscribed, sworn or affirmed and acknowledged before me by ETHEL A. CLIMENHAGA, the testatrix, GERALD J. BRINSER and ¢~,e,/?. ,a~t_~ .r'. ,~r:~/e, wimesses, this 5th day of November, 1996. (SEAL) -3- ~EG[STER OF WILLS CUMBERLAND COUNTY, PENNSYLVANIA CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: ETHEL A. CLIMENHAGA Date of Death: 9/7/2004 Will No. 21-04-0861 Admin, No. To the Register: I certi~ that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the Orphan's Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on 10/8/04 & 10/22/04 : Name Address EARL R. CLIMENHAGA HELEN CHRISTIE SAMUEL CLIMENHAGA VIOLA ROBSON 3440 S. JEFFERSON ST., APT. 1037 FALLS CHURCH 3801 FARR AVENUE, APT. 3-7 RIDGEWAY. ONTARIO BOX 598 KINDERSLEY. SASKATCHEWAN 4080 BEACH AVENUE PEACHLAND, BRITISH COLUMBIA VA 22041 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: Date: 10/22/2004 Capacity: Signature Name: GERALD J. BRINSER Address: 6 E MAIN STREET, P.O. BOX 323 PALMYRA PA 17079 Telephone(717) 838-6349 X Personal Representative Counsel for Personal Representative ETHEL A CLIMENHAGA Names and addresses Continuation of Certification of Notice Under Rule 5.6(a) Page 1 9/7/2004 Name VELMA HEISEY Address 544 CHICAGO AVENUE HARRISONBURG VA 2280? DORCAS FISHER #177 PLEASANT AVENUE NORTH BOX 3991 RIDGEWAYI ONTARIO ERNEST CLIMENHAGA 26491 FAIRWAY CIRCLE NEWHALL CA 91321 LOIS C. CLIMENHAGA 1613 IBIZA COVE NICEVILLE FL 32578 WESTERN CHRISTIAN [SCHOOLS] 3105 PADUA AVENUE CLAREMONT CA 9171 I MESSIAH VILLAGE P.O. BOX 2015 MECHANICSBURG PA 1705,,, BRETHREN IN CHRIST COOPERATIVE MINISTRIES 431 GRANTHAM ROAD GRANTHAM PA 1702 / UPLAND BRETHREN IN CHRIST CHURCH 845 W. ARROW HIGHLAND UPLAND CA 91781; BRETHREN IN CHRIST WORLD MISSIONS P.O. BOX 390 GRANTHAM PA 17027-0390 BRETHREN IN CHRIST FOUNDATION P.O. BOX 290 GRANTHAM PA 17017-0290 '04 !.: -6 0 John Z. Martin & Associates 926 MESSIAH VILLAGE · P.O. BOX2015 · MECHANICSBURG · PA 17055-2015 Ph. 717-795-9339 TO whom it may concern: Concerning a deposit toward inheritance tax. For file ~ 21-~-0861. To be sure Chech in the amount of $ 1,900.00 I am sending it to : For the estate 2~-04-0861 Register of wills agent Cumberland County. of Ethel A Climenhage. John Z. Martin. 926 Larch Loop Mechanicsburg, 17055 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT 280601 HARRISBURG, PA 17128 0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT REV 1162 EX(11-96) NO. CD 004694 MARTIN JOHN Z 926 LARCH LOOP MECHANICSBURG, PA 17055 ESTATE INFORMATION: SSN: 567-46-8747 FILE NUMBER: 2104-0861 DECEDENT NAME: CLIMENHAGA ETHEL A DATE OF PAYMENT: 12/06/2004 POSTMARK DATE: 1 2/03/2004 COUNTY: CUMBERLAND DATE OF DEATH: 09/07/2004 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 ,81,900.00 TOTAL AMOUNT PAID: $1,900.00 REMARKS: SEAL INITIALS: JA RECEIVED BY: GLENDA FARNER STRASBAUGH REGISTER OF WILLS REGISTER OF WILLS REV-1500EX+(e,OO) ~ ~: I ~"'. :~ .,J< ' . .A. '1'* ,'''7:.'': '~"'I! ",1'40 '"-'.('1. ~'.1:"'" COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128~601 DECEDENTS NAME (LAST. FIRST. AND MIDDLE INITIAL) I- Z W C W U w C CLlMENHAGA ETHEL A DATE Of DEATH (MM-DD-Year) REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL use ONLY FILE NUMBER 2 1 -0 4 0 8 6 1 ""Ci5UNTVCOOE -YENl- - -HUMBi:R-- SOCIAL SECURITY NUMBER DATE OF BIRTH (MM-DD-Year) 567-46-8747 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 09/07/2004 03/17/1912 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) N/A w !( ,,-Ul 0"''' wll;g :1:",-, 00." 0. .. 00 1. Onginal Return D 4. Limited Estate 1KJ 6. Decedent Died Testate (AtlachCOPyolWill) o 9. Litigation Proceeds Received SOCIAL SECURITY NUMBER o 2. Supplemental Return D 4a. Future Interest Compromise {date of death after 12-12-82) D 7. Decedent Maintained a living Trust (Atlach copy ofTrusQ o 10. Spousal Poverty Credit (date of death belween 12-31.91 and 1.1-95) o 3. Remainder Retum (date of death prior to 12-13-82} D 5. Federal Estate Tax Return Required Q.. 8. Total Number of Safe Deposit Boxes o 11. Election to tax under Sec. 9113(A) ,_h Soh 0) I- Z W C Z o 0. Ul W '" '" o o THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: NAME COMPLETE MAILING ADDRESS GERALD J. BRINSER 6 E. MAIN STREET FIRM NAME (If Applicable) BRINSER WAGNER & ZIMMERMAN P.O. BOX 323 TELEPHONE NUMBER 717 838-6348 PALMYRA PA 17078 1. Real Estate (Schedule A) (1) 2. Slocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 4. Mortga9es & Notes Receivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) (Schedule E) 6. JoinUy Owned Properiy (Schedule F) (6) D Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) (Schedule G or L) 6. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Admin~traUve Costs (Schedule H) (9) 10. Debts of Decedent Mortgage Liabilities, & Liens (Schedule I) (10) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (line 8 minus line 11) 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) z o i= :'3 ::l l- ii: c( u W It: OFFICIAL USE ONLY 215,090.911 I I ----.. ----------- (6) 215,090.91 26,739.62 12,425.97 (11) (12) (13) 39,165.59 175,925.32 158,332.77 14. Net Value Subject to Tax (line 12 minus line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES (14) 17,592.55 z o i= ~ ::l l1. ::E o U >< ~ 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 coUateral rate 19. Tax Due 0.00 X 0.00 (15) 0.00 0.00 X .045 (16) 0.00 17,592.56 X .12 (17) 2,111.11 0.00 X .15 (18) 0.00 (19) 2,111.11 20. 0 CHECK HERE IF YOU ARE REOUESTING A REFUND OF AN OVERPAYMENT > > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < Decedent's ComDlete Address: . STREET ADDRESS MESSIAH VILLAGE 100 MT. ALLEN DRIVE CITY MECHANICSBURG I STATE I ZIP PA 17055 Tax Payments and Credits: 1. Tax Due (Page 1 Une 19) 2. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount (1) 2,111.11 1 900.00 100 00 Totai Credits (A + B +C) (2) 2,000.00 3. InteresVPenalty if applicable D. Interest E. Penalty T otallnteresVPenalty ( D + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enterthe 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) A. Enter the interest on the tax due. (5A) 8. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (58) Make Check Payable to: REGISTER OF WILLS, AGENT 0.00 0.00 111.11 111.11 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Ves No a. retain the use or income ofthe property transferred; ........................................................................... D IZI b. retain the right to designate who shall use the property transferred or its income; ........................................ D IZI c. retain a reversionary interest; or ...................................................................................................... D lXl d. receive the promise for life of either payments, benefits or care? ............................................................. D IZI 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration?............................................................................................... D IZI 3. Did decedent own an 'in trustfo~ or payable upon death bank account or security at his or her death? ................. D IZI 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ....................................................................................................... D IZI 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 penalties ofpe~ury, I declare thai I have examined this return, includi~ accompanying schedules and statements, and to the besl of my knowledge and belief. itis true, correct and complete. Declaration of preparElJ er than the personal representative is based on a1lmformalion of 'IAlich preparer has any knowledge. SIGNATURE OF PER ON R ONSIBLEF FI ETURN DATE ADDRESS " PA 17078 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)l. 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 statute does not exemDt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax retum 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)(I.2)J. 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)(I)]. 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. ~9118(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) 'w COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF CLlMENHAGA ETHEL A SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FilE NUMBER 21 04 Indude the proceeds of litigation and the date the proceeds were received by the estate. All property jolntly-owned with right ollurvlvorshlp mUlt be dllcloled on Schedule F. 0861 ITEM NUMBER 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. DESCRIPTION AMERICAN EXPRESS FINANCIAL - ACCOUNT NO. 0080505836801002 AMERICAN EXPRESS FINANCIAL - ACCOUNT NO. 0090505836800002 ING USA ANNUITY AND LIFE INSURANCE COMPANY - CONTRACT #901 03247 PNC BANK - CHECKING ACCOUNT #-50-0000-0505 BRETHREN IN CHRIST FOUNDATION - SAVINGS ACCT. #1433 (INCLUDES ACCRUED INTEREST OF $41.94) BRETHREN IN CHRIST FOUNDATION - C.D. #1433-12518 (INCLUDES ACCRUED INTEREST OF $33.39) BRETHREN IN CHRIST FOUNDATION - C.D. #1433-13077 (INCLUDES ACCRUED INTEREST OF $313.51) 1.3809 UNITES OF USA REAL ESTATE INVESTMENT TRUST IDS AMEX PAYMENT (2 @ $200.00) ING USA ANNUITY PAYMENT (2 @ $145.91) DONATION TOWARDS FLOWERS USA REAL ESTATE INVESTMENT TRUST PAYMENTS (2 @$21.87) N f:\'~ j) J A,\.ST VALUE AT DATE OF DEATH 23,156.38 69,815.70 6,832.55 31,710.67 10,048.10 6,926.36 65,037.74 707.85 400.00 291.82 120.00 43.74 215090.91 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) ./ Ilea/guy -~ '" '-..... FAX ~.rnerican Express FInancial Ad . 5521 Carlisle Pike V1SOrs Mechanicsburg, P A 17050 Phone: (717) 591-/800 Fax: (717) 591-1811 To: Wendy, Gerald Brinser's office Fax: 717-838-6912 Phone: From: Chris Zeiders Date: 11/30/04 Re: Ethel Climenhaga Pages: 1 cc: o Urgent X For Review o Please Comment o Please Reply o Please Recycle Wendy, Per you request, following are the Date ofDeath values (1 In /04) for Ethel Climenhaga Select Fund A Acct No. # 0080 5058 3680 I 002 $23,156.38 Select Fund B Acct No. #0090 5058 3680 0 002 $69,815.70 Please call should you have any other questions. This communication and all attachments are confidential and may be legally privileged. If you are not the intended recipient, (i) please do not read ordisclosc any content to others, (ii) please notify the sender by reply fe-mail or fax) immediately, and (iii) plca<e destroy this document. Failure to follow this process may be unlawful and subject 10 prosecution. Thank you for your cooperation. ING .it> November 26, 2004 Estate Of Ethel A Climenhaga C/O John Z Martin, executive 926 Larch Loop Mechanlcsburg, PA 17055-8613 Re: 90103247 - Ethel A Cllmenhaga Dear Beneficiary: Enclosed is a check in the amount of $6,832.55, which represents the claim proceeds from this contract. The check consists of the Accumulation Value of the contract as of the date after the last financial transaction, plus additional interest credited from October 16, 2004 to November 24, 2004. The amounts are shown below: Accumulation Value Interest Federal Income Tax State Income Tax Total Benefit $ $ $ $ $ 6,800.49 32.06 0.00 0.00 6,832.55 Early next year, you will receive a Form 1099-R that will provide additional Information. If we may be of service to you in the future, please call our Customer Service Center at 1-800-369-5303:' ) Sincerely, . . d AAiolU }Wi1uu Ov Natalie Kincaid Claims Examiner Enclosure 909 Locust Street Des Moines. lA 50309-2899 1/1'.f:...:~ Brelhren III Chrisl FOU~DATION j'I'1l (/Il ('1(/( Sel'vIcesj"l' rei II Ii/it! ,';1(>(\'(11'(/'" POST OFFICE BOX 290 431 GRANTHAM ROAD GRANTHAM, PA 17027 December I, 2004 Mr. Gerald J, Brinser Brinser, Wagner & Zimmerman P,O, Box 323 Palmyra, PA 17078 RE: Ethel A. Climenhaga Estate SS #: 567-46-8747 Dear Mr. Brinser: At her date of death, September 7, 2004, Ethel A. Climenhaga had three investments with the Brethren in Christ Foundation. Please find the requested information in the table below, Account Date-of-Death Accrued Total Date-of- Number Tvoe Balance loterest Death Value 1433 Savings 10,006.16 41.94 10,048,10 1433-12518 Certificate 6,892,97 33.39 6,926,36 1433-13077 Certificate 64,724.23 313.51 65,037.74 There are no joint owners or beneficiaries listed for the above accounts, If I can be of further assistance, please do not hesitate to contact me at 717-697-2634, Extension #5420, or at kiacobs@messiah.edu. Sincerely, ~~:)~ Account Officer krj Phone: (717) 697-2634 . Fax: (717) 697-7714 . E-mail bicf@messiah.edu REV.1511 EX+ (12.99) * COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF CLlMENHAGA ETHEL A SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER 21 04 0861 Debts 01 decedent mUlt be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. COCKLIN FUNERAL HOME INC 7,632.19 2. GINGRICH MEMORIALS - HEADSTONE 610.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) JOHN Z. MARTIN 9,000.00 Sooal Secunty Numbe~s)IEIN Numberof Personal Representative(s) Street Address 926 LARCH LOOP City MECHANICSBURG State PA Zip 17055 Yea~s) Commission Paid: 2. AttomeyFees BRINSER, WAGNER & ZIMMERMAN 9,000.00 3. Family Exemption: (If decedents address is not the same as claimants, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. ProbsteFees REGISTER OF WILLS 269.00 5. Accountanfs Fees 6. Tax Return Prepare~s Fees 7. REGISTER OF WILLS - ADDITIONAL COST OF LETTERS 35.00 8. THE SENTINEL - LEGAL ADVERTISING 88.43 9. CUMBERLAND LAW JOURNAL - LEGAL ADVERTISING 75.00 10. TAX RETURN FILING FEE 15.00 11. INVENTORY FILING FEE 15.00 TOTAL (Also enter On line 9, Recapitulation) $ 26 739.62 (II more space" needed, insert additional sh_ of the same size) REV-'512EX + (11-98) * COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF CLlMENHAGA ETHEL A SCHEDULE. DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS Includ. unrelmbunsed medlcol .xpen.... FILE NUMBER 21 04 0861 ITEM NUM8ER DESCRIPTION 1. MESSIAH VILLAGE 2. PHARMERICA VALUE AT DATE OF DEATH 11,943.42 482.55 '- - TOTAL (Also enter on line 10, Recapitulation) $ (If more space ~ needed, Insert addnional sheels of the same size) 12425.97 ~EV."'3~'I" COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARIES FILE NUMBER ~I"'-' ,.,,^ A 71 D4 nRF;1 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not L\$l Trustee(s) OF ESTATE 1. TAXABLE DISTRIBUTIONS pndude OU~hl ~usal distributions, and transfers under Sec. 91 16 (a (1. )] 1. EARL R. CLlMENHAGA Sibling 2,199.07 3440 S JEFFERSON ST, FALLS CHURCH, VA 22041 2. HELEN CHRISTIE Sibling 2,199.07 3801 FARR AVENUE, RIDGEWAY, ONTARIO 3. SAMUEL CLlMENHAGA Sibling 2,199.07 BOX 598 KINDERSLEY, SASKATCHEWAN 4. VIOLA ROBSON Sibling 2,199.07 4080 BEACH AVE., PEACHLAND, BRITISH COLUMBIA 5. VELMA HEISEY Sibling 2,199.07 544 CHICAGO AVENUE, HARRISONBURG, VA 22802 6. ERNEST CLlMENHAGA Sibling 2,199.07 26491 FAIRWAY CIRCLE, NEWHALL, CA 91321 7. LOIS C. CLlMENHAGA Sibling 2,199.07 1613 IBIZA COVE, NICEVILLE, FL 32578 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. WESTERN CHRISTIAN SCHOOLS (10%) 17,592.53 3105 PADUA AVENUE, CLAREMONT, CA 91711 2. MESSIAH VILLAGE (10%) 17,592.53 100 MT. ALLEN DRIVE, MECHANICSBURG, PA 17055 3. BRETHREN IN CHRIST COOPERATIVE MINISTRIES (20%) 35,185.06 431 GRANTHAM ROAD, GRANTHAM, PA 17027 TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 158332.77 (If more space is needed, insert additional sheets of the same size) Continuation of REV-1500 Inheritance Tax Return Resident Decedent CLIMENHAGA, ETHEL A. Decedenfs Name Page 1 21 04 0861 File Number Schedule J - Beneficiaries - 1 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSONISl RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS (include outright spousal distributions) 8. DORCAS FISHER Sibling 2,199.07 #177 PLEASEANT AVE N, BOX 399, RIDGEWAY, ONTARIO Continuation of REV-1500 Inheritance Tax Return Resident Decedent CLIMENHAGA, ETHEL A. Decedent's Name Page 2 21 04 0861 File Number Schedule J - Beneficiaries - 2B B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 4. UPLAND BRETHREN IN CHRIST CHURCH 845 W. ARROW HIGHLAND, UPLAND, CA 91786 (10%) 17,592.53 5. BRETHREN IN CHRIST WORLD MISSIONS P.O. BOX 390, GRANTHAM, PA 17028-0390 (20%) 35,185.06 6. BRETHREN IN CHRIST FOUNDATION P.O. BOX 290, GRANTHAM, PA 17028-0290 (20%) 35,185.06 SUBTOTAL SCHEDULE J.2B 87,962.65 " , CC~fY WILL OF ETHEL A. CLIMENHAGA I, ETHEL A. CLlMENHAGA, currently of Upper Allen Township, Cumberland County, Pennsylvania, realizing the uncertainty of this life, but with confidence in God and trust in His Son, my Lord and Savior, Jesus Christ, who died for my sins upon the cross and rose again to redeem me and give me eternal life, do hereby make, publish and declare this to be my Last Will and Testament, hereby revoking any and all prior Wills and Codicils made by me. I. I direct that all my just debts and funeral expenses be paid from the assets of my estate as soon as practicable after my demise. II. I direct that all estate and inheritance taxes that may be assessed in consequence of my death, shall be paid out of the principal of my general estate to the same effect as if said taxes were expenses of administration and all property includable in my taxable estate whether or not passing under this Will shall be free and clear thereof. III. I bequeath unto my sister, Velma Heisey, any tangible personal property which she may desire. The balance of my tangible personal property I bequeath unto Messiah Village, Mechanicsburg, Pennsylvania, to be used as it sees best. IV. All the rest, residue and remainder of my estate, of whatever nature and wherever situate, including property over which I hold a power of appointment, I devise and bequeath as follows: A. Ten percent (10%) unto Western Christian, Claremont, California, to be used as it sees best; B. Ten percent (10%) unto Upland Brethren In Christ Church, Upland, California, to be used as it sees best; C. Ten percent (10%) unto Messiah Village, Mechanicsburg, Pennsylvania, to be used in its Endowment Fund; ~ -1- C%ctd a. &ntbnX ;;a/ . . D. Ten percent (10%) to be divided equally among my brothers and sisters who survive me; E. Twenty percent (20%) unto Brethren In Christ World Missions, Grantham, Pennsylvania, to be used as it sees best; F. Twenty percent (20%) unto Brethren In Christ Cooperative Ministries, Grantham, Pennsylvania, to be used as it sees best; G. Twenty percent (20%) unto The Jacob Engle Foundation, Inc., Grantham, Pennsylvania, to be used as it sees best. V. I appoint John Z. Martin Executor of this my Will. In the event that he fails to qualify or ceases to act as Executor, I appoint Gerald 1. Brinser, Esquire, Executor of this my Will. VI. I direct that no bond be required of my fiduciary for the faithful performance of his duties in any jurisdiction. IN WITNESS WHEREOF, I, ETHEL A. CLIMENHAGA, herewith set my hand to this my Last Will, typewritten on two (2) sheets of paper including the attestation clause and signatures of witnesses, this 5th day of November, 1996. dt ETHEL A. CLIMENHAGA Signed by ETHEL A. CLIMENHAGA, by her declared to be her Will in our presence, who have hereunto subscribed our names as witnesses in her presence and at her request, this 5th day of November, 1996. .L<-~ G~~R~ residing at ~4.12 b~. p,,- , residing at -2- .- - COMMONWEALTH OF PENNSYLVANIA COUNTY OF (J t'.''1c>e:~ tl'JlJ;J WE, ETHEL A. CLIMENHAGA, GERALD 1. BRINSER andCIf,f'(T")~R J. ~/r/'-~,t , the testatrix and the witnesses, respectively, whose names are signed to the attached or foregoing instrument, being fIrst duly affIrmed, do hereby declare to the undersigned authority that the testatrix signed and executed the instrument as her Last Will and that she signed wi11ingly (or willingly directed another to sign for her), and that she executed it as her free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the testatrix, signed the Will as witnesses and that to the best of our knowledge the testatrix was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. ~(j.~Ji J ETHEL A. CLIMENHAGA 7 ~.f M~~,- WITNESS y W1~~d I/i- Subscribed, sworn or affIrmed and acknowledged before me by ETHEL A. CLIMENHAGA, the testatrix, GERALD J. BRINSER and c..'I/l.I/7. MU .T. ,l'uf"F'f.(, witnesses, this 5th day of November, 1996. (SEAL) ~a ~ &-o~~ Notary PJllilic r.--.-.-----..-.----- L NOlor;". 3""1 ~ " Mary' l . R~'T',";J 'f\:n':,:ry Phi' t 'e'\ ,r r J! ~ '~"'" ~ '" U Ie .~;~~. n"e,n ~'N:1., Cumbedand Count.,. . ~." 'Jom/71'iG.:;IQro Expir'2S Jen. 13, 1998 Memoo, Pllru1S,'!vaniaAssaiallon of NotsiiesJ -3- REGISTER OF WILLS CUMBERLAND COUNTY, PENNSYLVANIA INVENTORY Estate of CLlMENHAGA. ETHEL A. , Deceased No.21 04 0861 Date of Death 9/7/2004 Social Security No. 567-46-8747 also known as Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following inventory include all of the personal assets wherever situate and all of the real estate in the Commonweatth 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 the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory. Ime verify that the statements made in this inventory are true and correct. I/We understand that false statements herein made are subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. Personal Representative: Name of Attorney: GERALD J. BRINSER 1.0. No.: 09655 Address: 6 E. MAIN STREET, P.O. BOX 323 PALMYRA PA 17078 Telephone: (717)838-6348 Description Cash, Bank Deposits, & Misc. Personal Property: Val~e AMERICAN EXPRESS FINANCIAL - ACCOUNT NO. 0080505836801002 23,156.38 AMERICAN EXPRESS FINANCIAL - ACCOUNT NO. 0090505836800002 69,815.70 ING USA ANNUITY AND LIFE INSURANCE CO - CONTRACT #90103247 6,832.55 PNC BANK - CHECKING ACCOUNT #-50-0000-0505 31,710.67 BRETHREN IN CHRIST FOUNDATION - SAVINGS ACCT. #1433 (INCLUDES ACCRUED INTEREST OF $41.94) 10,048.10 Total (Attach Add~ional Sheets if necessary) 215,090.91 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. RW-4 Continuation of Inventory CUMENHAGA, ETHEL A. 21 04 0861 PaQe 1 Description of Inventory Description BRETHREN IN CHRIST FOUNDATION - C.D. #1433-12518 (INCLUDES ACCRUED INTEREST OF $33.39) Value 6,926.36 BRETHREN IN CHRIST FOUNDATION - C.D. #1433-13077 (INCLUDES ACCRUED INTEREST OF $313.51) 65,037.74 1.3809 UNITES OF USA REAL ESTATE INVESTMENT TRUST 707.85 IDS AMEX PAYMENT (2 @$200.00) 400.00 ING USA ANNUITY PAYMENT (2 @ $145.91) 291.82 DONATION TOWARDS FLOWERS 120.00 USA REAL ESTATE INVESTMENT TRUST PAYMENTS (2 @ $21.87) 43.74 Subtotal $ 73,527.51 215,090.91 Grand Total $ 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 BRINSER GERALD J 6 E MAIN STREET. 2ND FLOOR POBOX 323 PALMYRA. PA 17078 __n__~. fOld ESTATE INFORMATION: SSN: 567-46-8747 FILE NUMBER: 2104-0861 DECEDENT NAME: CLlMENHAGA ETHEL A DATE OF PAYMENT: 06/08/2005 POSTMARK DATE: 06/07/2005 COUNTY: CUMBERLAND DATE OF DEATH: 09/07/2004 NO. CD 005409 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $111.11 I I I I I I I I TOTAL AMOUNT PAID: $111.11 REMARKS: CHECK# 854 SEAL INITIALS: JA RECEIVED BY: REGISTER OF WILLS GLENDA FARNER STRASBAUGH REGISTER OF WILLS 08-22-2005 CLIMENHAGA 09-07-2004 21 04-0861 CUMBERLAND 101 APPEAL DATE: 10-21-2005 (See reverse side under Objections) Amount Remitted I I 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 +-- REv:is47-Ex-AFP-ioi:osi-NOTICE"OF-INHERITANCE-TAX-APPRAIsEMENT:-ALLOWANCE-OR--------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ETHEL A FILE NO. 21 04-0861 ACN 101 .r".J.XllpOCD.F rr,,,- "F BUREAU OF INDI~ ,~s...:ir:\A: \_) INHERITANCE TAX DIY~nON'.:'~'T:~"" PO BDX Z806Dl'.;-',~>" . , HARRISBURG PA 17128-0601" .. COMNONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX Z~r'; I, I ,,~ "n li.~.1..i h',-,v '_.' '_' Pi; 1\; 24 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN Cc-C 1:,1 GERAl@'JIIRINSER BRINSER ETAL PO BOX 323 PALMYRA PA 17078 ESTATE OF CLIMENHAGA '*' REV-1547 EX AFP (06-05) ETHEL A TAX RETURN WAS: I X I ACCEPTED AS FILED I CHANGED DATE 08-22-2005 I~ an assessment was issued previoUSlY, lines 14, 15 and/or 16, 17, 18 and 19 will r~lect ~igures that include the total o~ ~ returns assessed to date. ASSESSMENT OF TAX: IS. A.ount of Line 14 at Spousal rate (15) 16. A.ount of Line 14 taxable at Lineal/Class A rat. (16) 17. Anount of Line 14 at Sibling rat. (17) 18. Amount of Line 14 taxable at Collateral/Class Brat. (18) 19. Principal Tax Due T X R I : RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule AJ 2. Stocks and Bonds (Schedule BJ 3. Closely Held Stock/Partnership Interest (Schedule C) 4. Mortgages/Notes Receivable (Schedule DJ S. CashlBank Deposi~s/"isc. Personal Property (Schedule EJ 6. Jointly Owned Property (Schedule f) 7. Transfers (Schedule G) 8. Total Assets III 121 131 (41 (51 161 171 .00 .00 .00 .00 215.090.91 .00 .00 (8) APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule X) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Govern..ntal Bequests; Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subiect to Tax (91 1101 26,739.62 12.425.97 1111 1121 1131 1141 NOTE: .00 X .00 X 17,592.56 X .00 X 00 = 045 = 12 = 15 = 1191= + INTEREST/PEN PAID (-I 100.00 .00 AMOUNT PAlO 1,900.00 111.11 DATE 12-03-2004 06-07-2005 NUtlBER CD004694 CD005409 ~. TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE IF PAID AFTER DATE INDICATEO, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. NOTE: To insure proper credit to your account, ~it the upper portion of this form with your tax pa~nt. 215,090.91 39.16~ 59 175,925.32 158,332.77 17,592.55 .00 .00 2,111.11 .00 2,111.11 2,111.11 .00 .00 .00 IF TOTAL DUE IS LESS THAN 01, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CRI, YOU MAY BE DUE A REFUND. SEE REVI!;'R~~ l::.Tns: nl!:' TUTe. r''''...... --- -..-------- STATUS REPORT UNDER RULE 6.12 Name of Decedent: ETHEL A. CLlMENHAGA Date of Death: 9/7/2004 Will No. 2004-00861 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-captioned estate: 1 . State whether administration of the estate is complete: Yes X No 2 . If the 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. account with the Court? Did the personal representative file a final Yes No X 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 X No d . Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Date: 4/5/2006 AM1cL g-. ~~fc / tofu.. Signature ' GERALD J. BRINSER Name (Please type or print) 6 E. MAIN STREET, P.O. BOX 323 PALMYRA PA 17078 Address ( 717 ) 838- 6348 Tel. No . Capac ity : Personal Representative X Counsel for personal representative ,-; - ..I ;.' \ .~