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HomeMy WebLinkAbout07-02-12 (5)1505610101 REV-1500 Ex `°1.1°' ' OFFICIAL USE ONLY PA Department of Revenue pennsylvania Bureau of Individual Taxes ~"AA,ME~,o County Code Year File Number Po Box z8o6o1 pINHERITANCE TAX RETURN vv~~ ii ~} Harrisburg, PA i~iz8-o6oi RESIDENT DECEDENT fi" I ~ ~ ~ ~',~ _7 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY Decedent's Last Name Gertze~ Suffix D~c_edent,> First flame V ~ I rrn (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI I MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number gurbur~. G'~rtze~ 7! 7 7~2 246 1 First line of address ~ ~ 5 Mu Vic, r c Second line of address City or Post Office Enc Ia ~ c ct cl State ZIP Code REGISTER OF WILLS USE ONLY r.a ~"~ rt _° r, ~ ~ C~ TE FILED "' ~ ~ ' --i '"` t P ~ t ~7 ~' ~ 5 G ~i'~ ~ c~ ~~ ~ Correspondent's a-mail address: bC~, ~^U ~'rl 1~:4 ~~ ~~ ~ • G Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON f2ESP0(+ISIBLE FOR FILING RETURN DATE ADDRESS ~ nC ~ `~ .' ~~ ~ I Q 83 `~ MG~~r~ ~~~ SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505610101 1505610101 J ~~ J 1505610105 REV-1500 EX y Number it ial Secur Soc nt' s e Deced / ' ~ ~j ~ [~ 7 ~ 2 -I v Ll ~ l~ ~ ~ T Decedent's Name: RECAPITULATION 1. Real Estate (Schedule A) ............................................ . 1. • ...................................... 2. Stocks and Bonds (Schedule B) . 2' • 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .... . 3. 4. Mortgages and Notes Receivable (Schedule D) .......................... . 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)...... . 5. ~ 1 Q I 3 ~ ~* 6. Jointly Owned Property (Schedule F) p Separate Billing Requested ..... .. 6. 7. Inter-Vivos Transfers ~ Miscellaneous Non-Probate Property 7 ~ (Schedule G) p Separate Billing Requested...... .. . 8 /'` ` Z ~j ( ~ U ` `~ ~ ~ " 9 ) ................ 8. Total Gross Assets (total Lines 1 throw h 7 • • • ~ • ~ • • • • • ~ • • 9. Funeral Expenses and Administrative Costs (Schedule H) ................. .. 9. ~ (1 3 ~ • ~1 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............ .. 10. J ~ • I Q 2 ~ 11 - 5 I I S ~ ~) 11. Total Deductions (total Lines 9 and 10) ............................... . .. ;, , 12. Net Value of Estate (Line 8 minus Line 11) ............................ .. 12. o' -Z tr ~ I (~ J Q c a ~ 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which 13 • an election to tax has not been made (Schedule J) ...................... .. . I ~ U 7 ~ c 14. Net Value Subject to Tax (Line 12 minus Line 13) ..................... ... 14. TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 15. (a)(1.2) X .0_ 16. Amount of Line 14~~able ~ I ~ 7 $ ~ ~+c ~ at lineal rate X .0 ~ J L7 16 ~ 3 2 ` l ~j 17. Amount of Line 14 taxable • 17 ~ at sibling rate X .12 18. Amount of Line 14 taxable 18 , at collateral rate X .15 ;,: -, , . 19. TAX DUE .........................................................19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 1505610105 Side 2 5~27C%, 1505610105 O REV-15G0 EX Page 3 Decedent's Complete Address: mac; I m c, - ~ re~,z~ ~(~~--~ze,-, STREET ADDRESS --- ---- ------ En~~ju clrY - --------------- -_ Enci~ Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments _ B. Discount 3. Interest 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 5 3 2. 7C Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS D'd ~. i decedent make a transfer and: Yes No a. retain the use or income of the property transferred :........................................................................ b. retain the right to designate who shall use the property transferred or its income : ..................................... ....... ^ c. retain a reversionary interest; or .............................................................. d. receive the promise for life of either payments, benefits or care? .................................... 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ............................... ... Did decedent own an "in trust for" orpayable-upon-death bank account or security at his or her death? ........ ^ ... 4. Did decedent own an individual retirement account, annuity or other non-probate property, which ... contains a beneficiary designation? .................................................................................................................. ...... ^ ~( IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)). For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)). • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. File Number o~ 2 - cr13 ~ 7 STATE i ZIP --- - -. - _ - PA------i j7c~~~~~~ c1) 532.7 Total Credits (A + B) (2) ~j (3) _ ~' (4) REV-1508E%•It 97) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT _ ESTATE OF rr~~ numocrt ~~Imu lr~n~ ~. ~e~-tzeM 2U~2- cc~3~~ Include the proceeds of litigation and the date the proceeds were received by the estate. All propeAy jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~. P~G~ E~t~t~ Acc~uri~ C ~i~53`i~7 IG, ~~~~ 43 Z ~ ~ Mai Scehan~c~,~S ~f:l'~S~nGi.) ~rd~ty ~`'~~h'"~ , knick-kr~~s)~ 2(1~.0~ TOTAL (Also enter on line 5, Recapitulation) $ i ~~ ~) (If more space is needed, insert additional sheets of the same size) Free Checking Account Statement (O For 24hour !<iformation, sign on to PNC Bank Online Banking ~ on pnc.com. Account number: 50-0105-3967 -continued Checks and Substitute Checks Check Date Reference number Amount paid number 87.50 05/X5 oRaos6oss For tha period 05/23/2012 to 08/22/2012 EST OF IRENE W GERTZEN DECD Primary account number: 50-0105-3967 Page 2 of 3 There is 1 check listed totaling $87.50. Daily Balance Detail Date Balance Date Balance Date Balance 05/23 16,781.43 05/25 16,693 J3 05/X9 16,813.93 PNC CHECK 12EAllY GIVES YOU THE POWER OF A CASH BUYER You're in control because we put the financing in place and the check in your hand.* At PNC Bank, you'll get a decision on your auto loan in as little as 15 minutes for most applications.* If approved, leave the bank with a blank' Checl; Ready check, or receive a check in the mail thA next business :hy.* Plus, now through July 20, get $100 for your new Check Ready Auto Loan. ** " Credit is aub(act to approval. Certain restrictions and conditions apply. Sams day check delivery excludes Sundays and holidays. "'`To quality tortM incamivs: (a) application must ba rscaiwd between Jum 1 and July 20, 2012 lb) applicairt must ba approved for a CMck Ready auto loan with a minimum loan smount or 57,300, (c) account Chocking ccoum within 90 days akartM accou,k is)bookad nreuntiveais not va di~on ex sting PNC aauro loansO, mey notibs ave1 eblario allurnabluts and s sub e t ito changa~at arrytinrtwithout ptic~ PNC Need to make a deposit? Try it on your SmartPhone. Using Mobile Deposit is easy. First download the Virtual Wallet App or PNC App, enter the amount and where you want the funds deposited, then take a picture of the front and back of the check. Third party message and data rates may apply. Use of the Mobile Deposit feature requires a supported camera-equipped device and you must download a PNC mobile banking app Eligible PNC Bank account and PNC Bank Online Banking required. Certain other restrictions apply. Sign on to Online Banking today to: Check Balances > 'T'ransfer Funds > Pay Bills > Monitor our accounts via email or text messa e with PNC Alerts Give Mom, Dad or Grad the gift they have always wanted the 1'NC Bank Visauy Gift Card is perfect for everyone on your gift Tist. PNC Bank Visa. Gift Carus are easy to purchase at r:ti/st of our branch locations. They come with a gift card carrier of your choice to highlight the special occasion. To learn more, visit your local PNC Bank branch or pnc.com/giftcard. Visa® is a registered trademark of Visa USA, Inc. ..fif<91£;7N-J£ Free Checking Account Statement PNC Bank For ~ period 05/23/2012 to 06/22/2012 r:~ ~ PNCBAi~1K Primary account number: 50-0105-3967 Page 1 of 3 Number of enclosures: 0 R 000758 EST OF IRENE W GERTZEN DECD BARBARA L GERTZEN EXTRX 835 MAGARO RD ENOLA PA 17025-1918 For 24hour banking, and transaction or interest rate information, sign on to PNC Bank Online Banking at pnc.com. 'a For customer service call 1-888-PNC-BANK Monday - Friday: 7 AM - 10 PM ET Saturday & Sunday: 8 AM - 5 PM ET Para servicio en espatiol, 1-866-HOLA-PNC MovingT Please contact us at 1-888-PNC-BANK ® Write to: Customer Service PO Box 609 Pittsburgl: PA 15230-9738 Visit us at pnc.com TDD terminal: 1-800-531-1648 For hearing impaired clients only n_~.I Free Checking Account Summary Aooount number: 50-0105-3987 ~Pler~ conptadtus ifdy u wou d like to set up this serv f~ r this account. Ovelnkatt coverage-Your account is currentlyoptod-out- You oryour joint owner may revoke your opt-in or opt-out choice at any time. To learn more about PNC Overdraft Solutions visit us online at pnc.com/overdraftsolutiona. Call t-877-588-3805, visit any branch, or Sign on to PNC Online Banking ,and select the "Overdraft Solutions' link under the Account Services section to manage both your Overdraft Coverage and Overdraft Protection settings. Balance Summary Ending Beginning Deposits and Checksd~uctlons balance balance other additions 50 87 16,813.93 . 16,781.43 120.00 Average monthly Charges balance and fees 16,796.34 .00 transaction Summary Checks paid/ Check Card POS Check Card/Bankcard POS PIN transactions withdrawals signed transactions 1 0 0 Total ATM PNC Bank Other Bank transactions ATM transactions ATM transactions tsL VT Iltllltl ~~ vo.acv......-- Barbara L Gertzen Extrx 0 0 0 /~ct~vlty ~eta~~ There was 1 Deposit or Other Addition Deposits and Other Additions Date Amount Description 05/29 120.00 Deposit Reference No. 525715758 totaling $720.00. PNf1M1 TM_ If1RA4AAC_N7An VAI wI AI AI AI nn7 nn 1Q'1n Free Checking Account Statement For 24-hour information, sign on to PNC Bank Online Banking on pnc.com. Account ntunber: 511-11 1 0 5-39fi7 -continued Deposits and Other Additions- continued Date Amount Description 05/`mil l,~i:;7.(iH`~llep~>sit Ruference No. fi23~70ri~{6 0.5%,1 123.(>U~I)rp~»it Reference No. Ci23470548 Checks and Substitute Checks Reference Check number Amount ~ paid number 20.00 ~ 04/27 ors5~5Hy7s =1,737.78 Obi/07 nrsh6sht~rl " Gap in check sequence There were 3 checks listed totaling SS_257.78. Daily galancs Detail Date Balance 04/24 12,787.17 04/25 1,.81`2.01 Balance Date Balance Date i ~ Or, 09 15,120.75 04;'7 12,7J` .01 0.5~ ~1 16,781.43 05/07 L~,fi20.75 /= DID YOU KNUW.•. "l'llE Glt>vA t >~:x Y vu>t~ ~.•.~•• •••...,..__ , _ _-- -- When you have a qualifying checking account and meet minimum balance and/or direct deposit requirements, you enjoy rewards or cash back on a PNC Cashl3r[ilden~, points? or Flexes Visas credit card. Here are some ofyour options: _ pNC CashBuilder credit card paired with Performance checking products otters the potential to earn even more cash back-- whateveryour level of spending. _ pNC points credit cardpaired with Perti~rmance checking products or Virtual Wallets others the potential toearn a bonus on the base points you earn. -PNC Flex Visa credit cardpaired with Performand save mon pon balance transfer llirom higher ate credit car ~ king oilers the opportunity to boost yor[r pointy earning potential a y To learn more about making your banking more rewarding, visit any PNC Bank branch or: > Call 1-877-CALL.-PNC (1-877-225-5762) > Visit us at pnc.com Credit cards subject to credit approval. PNC Rank, National Association (PNC Bank) is the creditor and issuer of the credit cards referenced above. Mernber FDIC CashBuilder, PNC points 'and PNC Flex are registered marks of The PNC Financial Services Group, [nc. Visa is a registered trademark of V isa International Service Association and used under license. Need to make a deposit'? "I'ry it on your SmartPhone. Using Mobile lleposit is easy. First download the Virtual Wallet App or YNC App, enter the amount and where you want the tirnds deposited, then take a picture of the front and back of the check. Third party message and data rates may apply. Use of the '.Mobile lleposit feature requires a supported camera-equipped device and you must ~__.....~.~.,,t ., hv[' mnhile banking app. Eli ible I'NC Bank account and PNC Bank Online Banking required. Certain other restrictions apply. Give Vlom, Uad or Grad the lift they have always wanted 1"he PNC Bank Visas Ciit3 Card is perfect fr~r everyon} °our chui~elto high ~ht Be spe`i,al occasions lv learn m re,pli it you lu al YNCI our branch locations. They come with a gift card tamer y Bank branch ur pnc.cum/~i1'tcard. .. For the poriod o4/Z4/Z01Z to 05/2Z/2o12 EST OF IRENE W GERTZEN DECD Primary account number: 50-0105-3967 Page 2 of 3 _ Check Date Reference number Amount paid number ri00.00 05~0~) OH4!)Ori711 VisaiR) is a registered trademark of Visa USA, Inc• Free Checking Account Statement ~ PNCBANK PNC Bat-k For f~1N porbd 04/24/2012 to 06/22/2012 000709 EST OF IRENE W GERTZEN DECD BARBARA L GERTZEN EXTRX 835 MAGARO RD ENOLA PA 17025-1918 Primary account number: 50-0105-3967 ~}/ ` Page 1 of 3 U ~ ` n(~ ~~ 5 I L I Number ofenclosures:0 For 24-hour banking, and transaction or interest rate information, sign on to PNC Bank Online Banking at pnc.com. 'jQ' For customer service call 1-888-PNC-BANK Monday - Friday: 7 AM - 10 PM ET Saturday & Sunday: 8 AM - 5 PM ET Para servicio en espaPfol, 1-866-HOLA-PNC fMoring7 Please contact us at 1-888-PNC-BANK ® Write to: Customer Service PO Box 609 Pittsburgh PA 15230-9738 V isit us at pnc.com TDD terminal: 1-800-531-1648 For hearing impaired clients only Enroll in online statements today through online banking, and have access to your checking and saving statements for up to 6 years. Enroll totia b visitin the Customer Service Tab in online bankin . Free Checking Account Summary Est Of Irene W Gertzen Decd Barbara L Gertzen Extrx Aaoount nuntlbor: 50-0105-3987 Avordraft Protoot0on has not been established for this account. Please contact us if you would like to set up this service. 4vordraft covorago-Your account is currently0ptod-Out. You or your joint owner may revoke your opt-in or opt-out choice at any time. To learn more about PNC Overdraft Solutions visit us online at pnc.com/overdraftsolutions. Call 1-877-588-3805, visit any branch, or Sign on to PNC Online Banking ,and select the "Overdraft Solutions" link under the Account Services section to manage both your Overdraft Coverage and Overdraft Protection settings. Balance Summary Beginning Deposits and Checks and other Ending balance other additions deductions balance 12,787.17 9,252.04 5,257.78 16,781.43 Average mo~th!y Charges balance and fees 14,227.05 •~ Transaction Summary Checks paid/ Check Card POS Check Gard/Bankcard withdrawals signed transactions POS PtN transactions 0 0 Total ATM PNC Bank Other Bank transactions ATM transactions ATM transactions 0 p 0 Act~~Ilty Detal~ Deposits and Other Additions Date Amount Description 04/25 24.£34 Transfer From Sub Account 0000005140023194 05/07 7,566.52 Deposit Reference No. 521673132 There were 4 Deposits and Other Additions totaling $8.252.04. no.,.,~tra any (~rhar Additions continued on next page o~in~e~ Tn+ ~noo+wno Bien ~~r.i~uisn.i nn'+ ~^+~'+-+ REV•i5t1 EX+(10-Ofi) ,. S~,HEDULE ~'I ~. ~'~ FUNERAL EXPENSES & COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF , ~t ZG n UcIrnG ~r"m~ I,v Debts of decedent must be reported on Schedule L ITEM DESCRIPTION NUMBER q, FUNERAL EXPENSES: ~.,J r~ i~~ ~ ~{ ~1CX' ~; fZ MU~ ~Un ac+ FILE NUMBER 2Ci 2 ~ Oo 3f~ 7 2~ •~7 32 g. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address State ZiP City _ - Year(s) Commission Paid: h ~ V~. ~l1 Z. Attorney Fees ~.~~ V ~~n 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address State Zip City -- Relationship of Claimant to Decedent /' e~t~ ; ~ h ~ r~ ~Gr~~l ~1 GCtt G, ~~ b ~ q, Probate Fees („~ rUn~ ~~ ~ ~ 5 " Qo REV l 5(1C) F~ - i~ y Fee 5. Accountant's Fees g. Tax Return Preparer's Fees 7. TOTAL (Also enter on line 9, Recapitulation) $ ~, C~y'~Z (If more space is needed, insert additional sheets of the same size) ~~~wrtoiv s~Py °~'~ ~~P~a~ 1`~~ AUER CREMATION SERVICES OF PE NNSYLYANIA, INC. ~~p~ ~iG' 4100 Jonestown Road • Harrisburg, PA 17109 • 1-800-720-8221 • ~'NSYL~AN~~~ Fax 717-541-9943 • Shawn E. Carper, Supervisor Feb 29, 2012 Ms. Barbara L. Gertzen 835 Magaro Road Enola, PA 17025 Velma Irene W. Gertzen - Deceased SPECIAL CHARGES X Direct Cremation Nationwide Guarantee Program $1,595.00 Worldwide Travel Protection TOTAL SPECIAL CHARGES PROFESSIONAL SERVICES X Services of Funeral Director & Staff Included Other Preparation of the Body Facilities & Staff for Memorial Service Staff & Equipment for Memorial Service Witnessing the Cremation Private Family Viewing/Witnessing Cremation Packaging And Forwarding Cremated Remains Personal Delivery of Cremated Remains Scattering of Cremated Remains Medical Documents/Courier Fee Memorial Service/Luncheon TOTAL PROFESSIONAL SERVICES AUTOMOTIVE EQUIPMENT X Removal Vehicle Included Lead Car/Clergy Car Family Car Service Vehicle TOTAL AUTOMOTIVE EQUIPMENT 120248 AS-5 $1,595.@0 $0.00 $0.00 MERCHANDISE Register Book Memorial Cards Thank You Cards Remembrance Package Cremation Container X Cardboard Container Urn Burial Vault Veterans Flag Case Grave/Memorial Marker $22,50 X 5 Laminated Obituaries TOTAL MERCHANDISE CASH ADVANCED ITEMS Grave Opening Cemetery Equipment $397.57 X Patriot News $337.25 X Times Leader (Ohio] Vault Service Charge Clergy Church/Organist/Soloist Flowers Included X Crematory Charge 25.00 X County Coroner Cremation Approval Fee $ X 10 Certified Copies of Death Certificate $60.0@ TOTAL CASH ADVANCED ITEMS SUMMARY OF CHARGES 1 595.00 Special Charges $ Professional Services $0.00 Automotive Equipment $0.@0 Merchandise $22.50 Cash Advanced Items 5819.82 SUB TOTAL $2,437.32 CREDITS -$1,000.00 AMOUNT PREPAID Date Mar 20, 1990 -$1537.68 TOTAL AMOUNT PAID Date May 21, 2012 $1,550.00 BALANCE DUE $22.50 $819.82 THIS STATEMENT MAY NOT REFLECT ALL NEWSPAPER CHARGES Dunn Law 3508 North Second Street Leo L. Dunn Harrisburg, PA 17110 Telephone 717-503-1207 Facsimile 717-232-7022 leo@leodunnlaw.com www.leodurmlaw.com Summary of Representation 05/07/12 Barbara L. Gertzen 03/01/12 Initial consultation .25 hours 03/26/12 Letters discussion .25 hours _ /~'~ ~U1 G~ ~ ~ ~-S~f~ ~1 K- 05/03/12 Email Discussion .25 hours ~~ Z~ ~ 05/05/12 Discussion .25 hours 05/07/ 12 PA Estate Tax forms 1.0 hour Total time 2.0 hours Fees $250/hour x 2 hours = $500 Total Amount Due $500 RECEIPT_FOR_PAYMENT GLENDA EARNER ST~'SBRegHster Of Wills Ct.~mberland County One CourthPAse17~13re Carlisle, GERTZEN ELMA IRENE_W Estate File No•~ Paid By Remarks: 2012-00387 BARBARA L GERTZEN WZ Fee/Tax Description PETITION LTRS TEST WILL SHORT CERTIFICATE JCS FEE AUTOMATION FEE Check# 1673 Total Received..••••••• Receipt Date: 3/30/2012 11:38:45 Receipt Time: 1069321 Receipt No•~ Receipt Distribution Payment Amount Payee Name COUNTY GENERAL FUN 20.00 CUMBERLAND CUMBERLAND COUNTY GENERAL GENERAL FUN FUN 15.00 24.00 CUMBERLAND BUREAU OF COUNTY RECEIP'T'S ~ CNTR GENERAL M.D FUN 23.50 CUMBERLAND COUNTY 5-~~-- ---------- ~i ~ _ .REV-1512 EX« (12-03) ~. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER ~cl m a l rz--t ~ itV . Gc--~zen 2 U 12 - 00 ~ 8 l Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. VALUE AT DATE ITEM DESCRIPTION OF DEATH NUMBER I-lornelGncl ~~ - PhySi~ul ~~(~Y .~ ~i6. i0 2L.c~ ~. ~~~~tur Gahm - ~d ~~~,r~st TOTAL (Also enter on line 10, Recapitulation) $ I 2 ~ ~ • (~ (If more space is needed, insert additional sheets of the same size) ~h~;l ~ 4~ ~2~~2 Statement HOMELAND NURSING HOME 1901 N FIFTH STREET HARRISBURG, PA 17102 Telephone: (717) 221-7900 Barbara Gertzen 835 Magaro Road Enola, Pa 17025 Statement Date: 4/4/2012 Re: Gertzen, Irene Account Nr: 2783 ---------- ----------------- g - Balance ----------------- p ------ Pa menu Descri tion Days Rate Char es y Date 1/1-1/19/12 Therapy Coinsurance 1/23-1/31/12 Therapy Coinsurance Deductible 1746.55 1746.55 1866.10 119.55 ~ ~ ~=~ `~ ~' 250.00 ~ 2116.10 Total $ 2116.10 PNC Bank, N PA 040 Southcenual '~.P~ PAY TO THE U~,`(~n ~n vv ORDER OF Two ~-OJ~u~d a~~ hUndt' f~ 1 80-1273!313 I b~ h n~-1 tI ?~ i2 ~ ~ 2,~16.i0 n e s,~•~„a ~..,•,.. ESTATE OF ~~~~ KM ~ I~Yi NP ~~ ~ 278 ~~' ~Tb14-- C~- (ni`t' ded~~b l~ FOR I;O 3 L 3 L 2? 38~: 500 LO 5 3_9_ 6 ?!'' IGHMNtK• FREEDCMBI.~1E_PPO AMediure Advanu~Ye PYO er ,,,,tewe snKw ~,,. ~~dev.+d."'tice~.w• dnK ewe c ,,.e ewe swew~~°" Claims Summary THIS IS NOT A BILL Member: IRENE W GERTZEN Identification #: 110 0 0 0 3 9 3 0 0 1 019993-075 Group~#; HIGHMARK INC Group 1 ame: For Customer Service call: 1- 8 0 0- 5 5 0- 8 7 2 Page 1 of 6 FEBRUARY 25, 2012 Provider Summary: Provider: HOMELAND CENTER 184128613e• $11,942.38 Provider ~? Total Prov120440220409 Claim 8: 12048033466 $0.00 57,464.50 Amount paid to the member: bill you: 52,116.10 Amount paid: the provider may If not already Paid, network facility• this facility has agreed to accept the allowance as These services were not ofoother contractual agreements. However,• payment in full because IGHMN~IC•~~~ FiNhAvenuePlace • 120FiflhAvenw F~EEDOMBL~JE.PPO \~\_/® Piricbutgh, PA 15222.3099 AMedicare Advantage PI'0 w~~ ewe snsw ~:,~ i~~"' ~.~ ~~ ewe aa~ „d ewe swero Ate' Important Plan Information BBWNDBaH BOCS88999960663666 IRENE W GERTZEN £ 835 MAGARO RD N N 0 4 5 ENOLA PA 17025 04512' ODOl a IGHNWZK. FREEDOMBLUEW PPO A Medicare Advantage PPO „;ghroahBlueSh;ea„~„«K~ Claims Summary ofehe Blue Cross and Blue ShieldASSUdatiun Page 2 of 6 Member: IRENE W GERTZEN Identification #: 110000393001 FEBRUARY 25, 2012 Group# 019993-075 Group Name: H I G H M A R K I N C PATIENT SUMMARY: 019311-055 Patient: IRENE W GERTZEN Benefit Period: 01/01/12 - 12/31/12 52,136.10 has been applied to Your 53,400.00 individual out-of-pocket amount. You have satisfied 5250.00 of Your 5250.00 individual out of network deductible. Please refer to Your benefit booklet or agreement for further information. Amount(s) shown may include totals from claims which are still being processed and for which you have not been notified. NN045129 N r- 1n M t>7 r c ~ ~ ~ o ' M ap ! ~p ri M M `~ ~' ~ O ~ ~ M 'c ~ '~ O ~ ~ o ~ ~ ~ o ~ N ~ o C N ~ .p N t~ 1n Ec .d N ~, c... ~ } M Q. Q ;~ \ \ X ~ `` o 00 0 0 0 0 0 ~ '' N ` (V N N< (V N N N Z 00 W 01 >~ O v ~ ~ y U ~~ U C ~ ed a LL ~~ C .-1 C C C C ~ ? t0 t0 ~ .~ ~ ~o W ~o ~ V apotOOR aD000+~3C00F" 7~t~ 7 71 7ti7 7~t 7 7~7 7 rl v7' .~ ~7' N H S e-1 ti7''-+ ~7' N 111.Oti U1 O~ 111 :: Ul O~ 111 fT 111 O~ t11. C T ~ G C 0~. 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Gen 1901 N 5Th Street Harrisburg, PA 17102 - - ~_ - 4/20/2012 -..- 1 GERIR000 uate of Last Payment: 4/20/2012 Amount: -30.52 Previous Balance: Patient: Irene W. Gertzen 0.00 Chart Number. GERIR000 Case: Nursing Home Dates Procedure Procedure Amount Paid by Paid B 01/11/12 11720 Charge Insurance y Debride Nails 1-5 Guarantor Adjustments Remainder 01/11/12 11719 30.00 -9.75 Trimming Nondystrophic Nails 21.00 '0.25 20.00 -20.77 -0.23 0.00 Pc:,d ~2- Es~+ e E~, t`; ~'N~'~ PNC Bey, Na. `~~~ Southcentral pq U46 4/2 3I~ 2 ~`ZO.G~O ~Z PAY TO 7HE ORDER OF~C.~,~y~' 60.1273/313 ~ Z~ 2012 _ ~ _ 2 c~ ~~ ESTATE pp DOLLARS Q s.9~;, ~•.~~. 'G -~ ^sl.r a' ~j~ FoR rTi ~ G ER ~RapO ' ~h~e ~ • ~~12~ ' "a~.~~ lj ~nGr ~ ~~ /~~~iz ~~ ..__- .O3131~2?38~ ---- ~ - S0D 10 ~; ...... .. ... 53967n• ........ ~ 1 ~_ ~ .. ... .. .. . ~. ~ - •1 ~_ ~_ ,~. 0.00 ~ _ ............... 0.00 20.00 20.00 ~~~~~ mill ~trt~ ~~,~~~tYYt~ert'~~,;~ 30 ~~.~ ~; ~ E.?., CLEr CL OrF O~~N;~~i'~ ~~~i;T I, VELMA IRENE W. GERTZEN, of Enola, Cumberland County, Pennsylvania, being of sound mind and memory, do make, publish and declare this my Last Will and Testament, hereby revoking all former wills and codicils made by me. A. DEBTS AND EXPENSES: I will and direct my personal representative to pay all legally enforceable debts, including the expenses of my last illness and funeral expenses, current bills and any and all other expenses incurred in administering my estate. B. FAMILY IDENTIFICATION: My husband and parents are deceased. My children are BARRY L. GERTZEN (deceased), BARBARA L. GERTZEN and ARLENE F. WITKOSKI. I have no grandchildren at this time. C. PERSONAL PROPERTY: If my daughter, BARBARA L. GERTZEN, survives me, my personal effects, including automobiles, boats, sporting equipment, jewelry, furniture, furnishings, china, glassware, silver and household equipment (except those items which are specifically given to a beneficiary elsewhere in this Last Will and Testament in which case said specific gift shall take precedence over this paragraph) shall be distributed to my surviving daughter, BARBARA L. GERTZEN. If my daughter, BARBARA L. GERTZEN, does not survive me, then I direct that my personal representative(s) divide my personal effects, as described above (except those items which are specifically given to a beneficiary elsewhere in this Last Will and Testament in which case said specific gift shall take precedence over this paragraph), among the following named beneficiaries who survive, as the surviving named beneficiaries agree or, failing such agreement, in such manner as my personal representative(s) may deem equitable. If my daughter, BARBARA L. GERTZEN, does not survive me and if the surviving named beneficiaries do not agree, I give my personal representative(s) full discretion to determine the division and distribution of the articles above referred to between my surviving named beneficiaries, and such determination shall be binding on all persons. The named beneficiary for purposes of this paragraph is: ARLENE F. WITKOSKI. I attest to the Testator initialing this page: I have read and understood this page: WITNESSES: TESTATOR~:j ~.. ~~ y Page 1 of 8 Page 2, Last Will and Testament of Velma Irene W. Gertzen p. SPECIFIC GIFTS Item Beneficiary $1,000.00 ARLENE F. WITKOSKI E. ESTATE TAX PROVISIONS: My residuary estate remaining after compliance with the previous provisions is to be given to my daughter, BARBARA L. GERTZEN, if she survives me, but she shall have the right to disclaim all or any part of said residue. Upon said disclaimer of assets by either, the disclaimed whole or portion shall be distributed to and administered pursuant to the provisions for the Non-Marital Share as described hereunder. 1. NON-MARITAL SHARE Upon my death, the assets of this Non-Marital Share shall be divided among my named beneficiaries in equal shares. The named beneficiaries for purposes of this paragraph are ARLENE F. WITKOSKI. F. DISTRIBUTION OF RESIDUE: If my daughter, BARBARA L. GERTZEN, does not survive me, I give, devise and bequeath all of the rest, residue and remainder of my estate and property, of whatever kind and wherever situatId'If a named benefichary doesf not survive mey Igive the share of ARLENE F. WITKOSK said beneficiary to that beneficiary's issue by representation. G. HEIRS INTENTIONALLY NOT NAMED: I have consciously not named any other family member and their issue under the terms of this document. H. NO CONTEST PHRASE: If any beneficiary of this will or any trust created under this will, singly or in conjunction with any other person: 1. Contests or otherwise objects in any court to the validity of any of the following documents or amendments thereto (hereafter "Document" or "Documents") or of any of their provisions: WITNESSES: L ~~~ TESTATOR: ,~~ ~ ~ ' v ~~1~ ~ Page 3, Last Will and Testament of Velma Irene W. Gertzen a. this Last Will and Testament, b. any trust created pursuant to this Last Will and Testament, any beneficiary designation of an annuity, retirement plan, IRA, Keogh, pension or profit-sharing plan or insurance policy signed by me, d. a buy-sell agreement signed by me, e. a family partnership agreement, limited liability company, or related operating agreement signed or established by me; or 2. Seeks to obtain an adjudication in any court proceeding that a Document is void, or otherwise seeks to void, nullify or set aside a Document (or any of its provisions); Files suit on a creditor's claim filed in a probate of my estate against the estate, or any other Document, after rejection or lack of action by the respective fiduciary; 4. Files a petition or other pleading to change the character (community, separate, joint tenancy, partnership, domestic partnership) of property already characterized by a Document; 5. Claims ownership of any asset held by me in joint tenancy, other than as a surviving joint tenant; 6. Files a petition to probate homestead in a probate proceeding of my estate; 7. Files a petition for family allowance in a probate of my estate; or 8. Participates in any of the above actions in a manner adverse to the estate, such as conspiring with or assisting any person who takes any of the above actions, then the right of such beneficiary to take any interest given to him or her under this will or any trust created pursuant to this will shall be determined as it would have been determined had such beneficiary predeceased the testator without surviving issue. The personal representative is hereby authorized to defend, at the expense of the estate, any contest or other violation of this paragraph. Notwithstanding the foregoing, a WITNESSES: TESTATOR: ~~~- ~~~~ Page 4, Last Will and Testament of Velma Irene W. Gertzen "contest" shall include any action described above in an arbitration proceeding and shall not include any action described above solely in a mediation not preceded by the filing of a contest with the court. Notwithstanding the foregoing, this paragraph shall not apply so as to cause a forfeiture of any distribution otherwise qualifying for the federal estate tax marital deduction or charitable deduction. SURVIVORSHIP PHRASE: If any beneficiary dies prior to the entry of an order, decree, or judgment in my estate distributing the property in question, or within sixty (60) days after the date of my death, whichever is earlier, any interests which would have passed to said beneficiary under the provisions of this Last Will and Testament are to be disposed of according to the plan of distribution which would have been effective under this Last Will and Testament if such beneficiary had predeceased me, except that, if a'Simultaneous Death Provision' is included in this Last Will and Testament or in any codicil thereto, the Simultaneous Death Provision shall take precedence over the provisions of this paragraph in regard to survivorship of my partner. It is my intention that any property or interest which is distributed from my estate as a result of any transfer authorized by my personal representative prior to the death of said beneficiary will not be revoked or otherwise affected by the subsequent death of the distributee. PERSONAL REPRESENTATIVE(S): I constitute and appoint BARBARA L. GERTZEN personal representative of this my Last Will and Testament. I authorize and empower my personal representative to sell, transfer and convey any and all of the property of my estate, real and personal, and to execute, acknowledge and deliver good and sufficient transfers and conveyances thereof. 2. If BARBARA L. GERTZEN is unable or unwilling to serve as personal representative, Iconstitute and appoint ARLENE F. WITKOSKI as personal representative to serve with all rights and responsibilities given to the original personal representative(s). 3. If no personal representative named in this will is willing and able to act, a personal representative or co-personal representatives maybe selected by the court. The personal representative(s) so selected and appointed shall have all WITNESSES: TESTATOR: ~- ~ ~(~~ ~ ~~ Page 5, Last Will and Testament of Velma Irene W. Gertzen rights and responsibilities hereinbefore .given to the named personal representative(s). 4. No bond will be required of the personal representative. K. WILL CONSTRUCTION: 1. Wherever the context requires, the singular includes the plural, and the masculine includes the feminine and neuter. The words "child", "children", "grandchild" and "grandchildren" shall include legally adopted children and grandchildren and children and grandchildren born or adopted before or after the execution of this Last Will and Testament, but shall not include stepchildren or step grandchildren who have not been legally adopted. Also, in construing this will, the terms "lineal descendants" and "issue" shall include legally adopted lineal descendants and issue and lineal descendants and issue born or adopted before or after the execution of this will. 2. The phrases "issue by right of representation" and "issue by representation" shall mean lineal descendants, per stirpes. The phrase "his/her and/or their issue by representation" shall be interpreted so that if a beneficiary of this will is alive at the applicable date, the beneficiary's share is distributed to said beneficiary and issue do not take as beneficiaries, but if a beneficiary of this will is deceased as of the applicable date and the will provisions provide that the beneficiary's "issue by representation" take the deceased beneficiary's share, then that beneficiary's lineal descendants, per stirpes, take, inherit, and/or benefit as the deceased beneficiary's issue by representation or issue by right of representation. Issue shall mean lineal blood descendants and legally adopted descendants, unless stated otherwise. The phrase per stirpes shall mean (1) the division of distributable property into the number of equal shares sufficient to create one such share with respect to each then living descendant occupying the oldest generation in which there is at least one then living person, and one such share with respect to each deceased descendant occupying the same generation who is then survived by one or more descendants, and (2) distribution of each share so created with respect to a then living descendant to such descendant, and distribution of each deceased descendant's share equally among or between the deceased descendant's children, also per stirpes as defined in (1) above. 3. The word "testamentary" shall be construed as meaning arising after death, and shall not be construed to imply any requirement of a probate proceeding of any type. All references to I.R.C. § and/or Reg. § or Regulation § shall include any WITNESSES: TESTATOR: ~~~ ~~ ~ . .~. ,~.~~~' Page 6, Last Will and Testament of Velma Irene W. Gertzen amendments and/or equivalent successor section to said code or regulation. Trustee(s) includes any person(s), corporation(s) or other entity(ies) from time to time holding that office as soolmo me to time hold ng that office and also nc udes any person or corporation fr a special administrator. 'tne s: ~. Testa #:~- Page 7, Last Will and Testament of Velma Irene W. Gertzen IN WITNESS WHEREOF, I have hereunto set my hand and seal this 22"d day of May, 2010. WITNESSES: -~ ~ - /////////////~/ii~!~~ /J .~ /JE TESTATOR: -~~ ~ ~~ U ~tit~. ~~~ fv~ ~- VELMA IRENE W. GERTZEN Pennsylvania Self-Proving Clause Commonwealth of Pennsylvania County of Dauphin I, VELMA 1RENE W. GERTZEN, the testator, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; and that I signed it willingly and as my free and voluntary act for the purposes therein expressed. , ~~ V L A IRE W. GERTZEN Sworn or affirmed to and acknowledged before me by VELMA IRENE W. GERTZEN, the testator, this 22"d day of May, 2010. co~oriweA~n~ of PEr~vsnva~- (Se41 j Notarial seat ~~\~ leo 1. Dunn, Notary Pubik Susquehanna Twp., Dauphin County LEO L. DUNK, Notary Public My Cornmlaabrt Expires Jan. 17, 2012 Member, PenruykaMa Assoda0on M Nohrtes My commission expires Jan. 17, 2012 Affidavit Commonwealth of Pennsylvania County of Dauphin We, , L,~}-nJ~ 5~~ ~(J~t'~'L 1~u~ ~~..~F ~ and ~~l..fr,,,~_i ~ ~,, /~~._~= ,the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw testator sign and execute this will as his Last Will; that the testator signed willingly and executed it as his free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the testator, signed the will as a witness; and that to the best of our knowledge the testator was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. Page 8, Last Will and Testament of Velma Irene W. Gertzen S orn or affirmed to and subscribed to before me by ~/f~~i 5 ~ G~ pert ~ a May, 2010. and ~ ~~- ~~r-°~' !~ r~l~C,~~-,witnesses, this 22" ~~. Wit s~-y.- , / Pri Name: I~~JiS K . 1 ~~~c'-~ Print Address: 3~ v.~.,~ ~ '' .J ~~ ~ Witness '-? / Print Name: ~") i ~ ~';"~"' G' ~ ~~~J~- Print Address: ~ h :r,~~_~ ~ -~~~ ~Scal) con~oNwrJU.-rt~ of ~rrNSnvnr~- Nofetid sad ~aa L. Dunn, Notary Public Susquehanna Tvrp., Dauphin County My Commiubn Ezprss Jan. 17, 2012 Member. Pennsylvania Assodation of Notarbs a`~ day of ~: Witness _ Print Name: ~u ~ ~ ~wa Print Address: o~ ~/ ~ti~ ~- dA/1/ S iri/,4 G. ~ ~~/O _".-~. L O L. DLTNN, Notary Public My commission expires Jan. 17, 2012