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Home My WebLink About04-1051 PETITION FOR PROBATE and GRANT. OF ,LETTERS Estate of JOHN A. BOLLINGER No. T{ - ? ~ -- [~ ~)l also known as To: , Deceased. Social Security No. 175483251 The petition of the undersigned respectfully represents that: Register of Wills for the County of CUMBERLAND Commonwealth of Pennsylvania Your petitioner(s), who is/are 18 years of age or older and the execut ors in the last will of the above decedent, dated OCTOBER 29, 2004 and codicil(s) dated in the named (state relevant circumstances, e.g. renunciation, death of executor, etc.) Decedent was domiciled at death in CUMBERLAND County, Pennsylvania, with h is last family or principal residence at 48 SCARSDALE DRIVE. CAMP HILL. LOWER ALLEN TOWNSHIP, CUMBERLAND COUNTY, PENNSYLVANIA 17011 (list street, number and municipality) Decedent, then 49 years of age, died 11/5/2004 at HOLY SPIRIT HOSPITAL, CAMP HILL, PA 17011 Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted after execution of the will offered for probate; was not the victim cfa killing and was never adjudicated incompetent: Decedent at death owned property with estimated values as follows: (If domiciled in Pa.) All personal property (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: $ $ $ $ 7,000.00 WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s) presented herewith and the grant of letters testamentary thereon. (testamentary; administration c.t.a.; administration d.b.n.c.t.a.) 2466 MERCER STREET ~' ¢'-t-~ /~ Y/.~' (X'/,/r , HARRISBURG PA 17104 ~ ~R~ENE S. K~HR ~ ' ' OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA '[ SS COUNTY OF CUMBERLAND The petitioner(s) abovemamed swear(s) or affirm(s) that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner(s) and that as personal represen- tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. Sworn to or affimled~nd subscribed f. ,~/tq/'''/'~- before me this ! [ ' ~" day of l i NOVEMBER 2004.. ~ -, ' Rdeister Estate of JOHN A. BOLLINGER , Deceased DECREE OF PROBATE AND GRANT OF LETTERS AND NOW NOVEMBER i ,2004 , in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated 10/29/2004 described therein be admitted to probate and filed of record as the last will of JOHN A. BOLLINGER .; and Letters TESTAMENTARY are hereby granted to ARLENE S. KOHR FEES Probate, Letters, Et¢ ......... Shun Certificates (5 ). q ..... , ~ ATOT~ Fied MCk( 1/ .[ ~ ............... HAROLD S. IRWIN, III 29920 ATTORNEY (Sup. Ct. I.D. No.) 64 SOUTH PITT STREET CARLISLE PA 17013 ADDRESS 717-243-6090 PHONE OMMONWEALTH OF PENNSYLVARIA · DEPARTMENT OF HEALTH · VITAL RECORDS CERTIFICATE OF DEATH John A. Bollin Male ~ 175 -- 48 --t~SLI~ ~c ~% 48 Scarsdale Drive ~O~A~C~ .......... ~ompu ~ ~rogramer Lehr Bol]in~er James S. LAST WILL AND TESTAMENT I, JOHN A. BOLLINGER, of 48 Scarsdale Drive, Camp Hill, Cumberland County, Pennsylvania 17011, do hereby make, publish and declare this to be my last will and testament, hereby revoking all wills heretofore made by me. 1. I direct my personal representative to pay all of my debts, funeral and administrative expenses as soon as convenient after my decease. I direct that all inheritance taxes imposed or payable by reason of my death and interest and penalties thereon with respect to all property, whether or not such property passes under this Will, shatl be paid by my personal representative out of my estate. 2. I authorize and empower my personal representative to sell any realty and/or personalty owned by me at my death and not specifically devised or bequeathed herein, at public or private sale or sales and to give good and sufficient deeds and/or bills of sale therefore, in fee simple, as I could do if living. My representative is authorized and empowered to engage in any business in which I may be engaged at my death, for such period of time after my death as seems expedient to said representative. 3. I give, devise and bequeath all of my estate of whatever nature and wherever situate as follows: C. D. E. Any motor vehicle I may own at my death and my computer to my niece, Alisha K. Kohr; My digital camera and my printers to my nephew, Ralph Kohr; My Lord of the Rings DVD set to my friend, Holly Davis; My Babalon Five DVD set to my friend, Jake Grove; and all the Rest, residue and remainder to my sister, Arlene S. Kohr. 5. I nominate and appoint my sister, Arlene S. Kohr, to be the personal representative of my estate, to serve without bond. If she cannot or does not serve, then I appoint my niece, Alisha K. Kohr to be my substitute personal representative, also without bond. October, 2004. IN WITNESS WHEREOF, I have hereunto set my hand and seal this 29th day of JOl-~ A. BOLLIN'GER Signed, sealed, published and declared by the above-named person as and for a last will and testament, in our presence, who at said person's request, in said person's presence and in the presence of each other have hereunto set our names as subscribing witnesses. ACKNOWLEDGMENT AND AFFIDAVIT WE, JOHN A. BOLLINGER, RHONDA S. IRWIN and CONSTANCE T. HESS, the testator and witnesses respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the testator signed and executed the instrument as his last will and that he had signed willingly, and that he executed it as his free and voluntary act for the purpose herein expressed, and that each of the witnesses, in the presence and hearing of the testator, signed the will as a witness and that to the best of their knowledge the testator was, at that time, eighteen years of age or older, of sound mind and under no constraint or undue influence. JO/I,~ A. I~OLIzI~IGER STATE OF NEW YORK COUNTY OF ERIE . 'ss: : Subscribed, sworn to and acknowledged before me by JOHN A. BOLLINGER, the testator herein, and subscribed and sworn to before me by RHONDA S. IRWIN and CONSTANCE T. HESS, witnesses, this 29th day of October, 2004. - ~ ~ "~ , /, .~-'~ Notary Public , IN THE COURT OF COMMON PLEAS,CUMBERLAND COUNTY PENNSYLVANIA ORPHANS' ESTATE OF JOHN A BOLLINGER COURT DIVISION ) Register' Deceased) CLAIM To the Clerk of the Orphans' Court Division : Index and make proper entry in your official records of the claim of CITIBANK USA NA in the amount of $1,611.43 against the estate of the above-named decedent. This claim is filed under Section 3532 (b) (2) PEF Code, 20 Pa. C.S. ss. 3532 (b) (2) The said decedent, whose last known residence was at 48 SCARSDALE DR CAMP HILL PA 17011 Written notice of this claim was given to ARLENE KOHR 2466 MERCER ST HARRISBURG PA 17104 on December 7, 2004 (Claimant) DAVE HIPPENST] ,manager of Citicorp Credit Services, Inc. USA under limited power of attorney for CITIBANK USA NA 7930 NN 110TM ST KANSAS CITY, MO 64153 (Claimant's Address) Account #(s) 6011766303459736 GATEWAY POC $1611.43 CSS ** NO MORE DETAILS ON FILE **CRCD 840 RL 0001 OF 0001 08:53:32 12/06/04 BOLLINGER, JOHN A*'48 SCARSDALE DR**CAMP HILL*PA*17011-7938*6011766303459739*0 1105 1130 29W 450.00 ID 2000 0 7 0 01 LATE FEE 35.00 1611.43 .00 .00 35.00 .00 .00 35.00 1646.43 07394 07394 ADB MDSE ADB CASH CUR SALE .00 360.00 26.99 26.99 .00 .00 .00 .00 - 3~.oo IN THE COURT OF COMMON PLEAS,CUMBERLAND COUNTY PENNSYLVANIA ORPHANS' ESTATE OF JOHN A BOLLINGER COURT DIVISION ) Register's ~*~41051 Deceased) CLAIM To the Clerk of the Orphans' Court Division : Index and make proper entry in your official records of the claim of CITIBANK USA NA in the amount of $1,611.43 against the estate of the above-named decedent. This claim is filed under Section 3532 (b) (2) PEF Code, 20 Pa. C.S. ss. 3532 (b) (2) The said decedent, whose last known residence was at 48 SCARSDALE DR CAMP HILL PA 17011 Written notice of this claim was given to ARLENE KOHR 2466 MERCER ST HARRISBURG PA 17104 on December 7, 2004 DAVE HIPPENS~E~ ,manager of C~t~corp (Claimant) ~ . . Credit Services, Inc. USA under limited power of attorney for CITIBANK USA NA 7930 NN 110TM ST KANSAS CITY, MO 64153 (Claimant's Address) Account %(s) 6011766303459736 GATEWAY POC $1611.43 CSS ** NO MORE DETAILS ON FILE **CRCD 840 RL 0001 OF 0001 08:53:32 12/06/04 BOLLINGER, JOHN A*'48 SCARSDALE DR**CAMP HILL*PA*17011-7938*6011766303459739*0 1105 1130 29W 450.00 ID 2000 0 7 0 0t LATE FEE 35.00 1611.43 .00 .00 35.00 .00 .00 35.00 1646.43 07394 07394 ADB MDSE ADB CASH CUR SALE .00 360.00 26.99 26.99 .00 .00 .00 .00 kl 4 .q3 - 3 .oo REGISTER OF WILLS CUMBERLAND COUNTY, PENNSYLVANIA CERTIFICATION OF NOTICE UNDER RULE 5.61al Name of Decedent: JOHN A. BOLLINGER Date of Death: 11/5/2004 Will No. 2104-01051 Admin. No. 21 . 04 . 01051 To the Register: I certify 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 2/3/2005 Name Address ARLENE S. KOHR 2456 MERCER STREET HARRISBURG PA 17104 2823 CROYDEN STREET HARRISBURG PA 17104 2823 CROYDEN STREET HARRISBURG PA 17104 423 WALNUT STREET APT 217 HARRISBURG PA 17101 RALPH KOHR HOLLY DAVIS JAKE GROVE Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: NONE Date: 2/3/2004 Signature ~~O C) Name: HAROLD S. IRWIN. III Address: 64 SOUTH PITT STREET CARLISLE PA 17013 Telephone(717) - 2436090 (-.: Capacity: x Personal Representative Counsel for Personal Representative 0' Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717)240-6345 Date: 02/01/2005 IRWIN HAROLD SIll 64 SOUTH PITT STREET CARLISLE, PA 17013 RE: Estate of BOLLINGER JOHN A File Number: 2004-01051 Dear Sir/Madam: It has come to my attention that you have not filed the Certification of Notice Under Rule 5.7 (a) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within ten (10) days after giving proper notice to the beneficiaries and intestate heirs as required by subdivision (a) of Rule 5.7, shall file with the Register of Wills or Clerk of the Orphans' Court his/her Certification of Notice. This filing will become delinquent on 02/27/2005 Your prompt attention to this matter will be appreciated. Thank You. Sincerely, G6=~:~ Clerk of the Orphans' Court cc: File Personal Representative(s) Judge Cumberland County - Register Of wills One Courthouse Square Carlisle, PA 17013 Phone: (717)240-6345 Date: 02/01/2005 KORR ARLENE S 2466 MERCER STREET HARRISBURG, PA 17104 RE: Estate of BOLLINGER JOHN A File Number: 2004-01051 Dear Sir/Madam: It has come to my attention that you have not filed the Certification of Notice Under Rule 5.7 (a) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within ten (10) days after giving proper notice to the beneficiaries and intestate heirs as required by subdivision (a) of Rule 5.7, shall file with the Register of wills or Clerk of the Orphans' Court his/her Certification of Notice. This filing will become delinquent on 02/27/2005 Your prompt attention to this matter will be appreciated. Thank You. sr~~ GLENDA FARNER STRASBAUGR Clerk of the Orphans' Court cc: File Counsel Judge -. -- STATE OF Pennsylvania Ori9in~1 to be 'filed 2:00 Cumberland. . COUNTY - IN PROBATE In the Matter of the E3tate of No. 21- 0 4 - ID 051 John A Bollinqer CLAIM Citibank (SD) NA!Texaco c/o victor and Victor, Ltd . 1. Claimant 200 N. LaSalle. St. Ste.2800 Chicaao. IL 60601 has a claim (name and address) for $ 1228.36 against this estate, which is just and unpaid after a.llowing all just credits, deductions and set-offs. 2. The nature of the claim is that the deceased is indebted to Ci tibank (SD) NA/Texaco for purchases of merchandiseoor services ma e on charge card #1338420084 in the amount of $1228.36 as per the attac e affidavi. Atty!Agent AFFIDA VIT Gayle L Victor claim are true. Atty/Agent for f"OFFlCIAL SEA~ Rosanne Galve~ . . te of illinoIS Notary P~b\.'c. Sta 08113(2.006 My CommISSIon Bltp. ...- .- .. -- Signed and sworn to before me ORDER Name Gayle L Victor . Citibank (SD) NA!Texaco Allowed for S Attorney for Claimant 200 N. LaSalle, and costs. Class Address Ste 2800 . . 19_ City Chicago, IL 60601 312-641-5330 (Judge) Telephone Mailing and delivery of copy of claim waived. ,19_ Attorney for estate Executor Administrator Guardian Conservator Note: If claim is based upon a written instrument, a copy must be attached. ~t -::... Mailing and delivery of copy of claim waived. February' 09, 2)05 _~1t Attorney for estate Executor Administr:ltor Guardian Conservator I Gayle L Victor lcertify) lst:l.te on oathl that on February 09, 2005 .:U~ L copy of this claim was mailed {delivered in personl (mailedl by ordinary mail (mailed by registered mail. return receipt requestedl to Arlene S. Kohi (executor} ,. . . . ;1 ~ , ... , '.,', .,~' i; ,1_, Signed and sworn to before me February 09, 2005 ~ , -. (Notary Public} .... "'."- ; ,! 1 ( ;' ;'!flf .... " , NOTE: II claim is based upon a written instrument. a copy must be attached. I consent to allowance of this claim for S as 3. costs to be charged to the estate. class claim. .19_ Attorney for estate Executor Administrator Guardian Conservator Date of letters .19_ Claim date .19_ Set for hearing .19_ , ./' at _.m., room NOTE: Unless the legal representative or his attorney waives mailing and delivery. or consents to the allowance of the claim. a C'Opy of the claim MUST be mailed or delivered to the legal represenUtive AND to his attorney. II the claim is against the estate of a decedent and is filed on or before the claim date. the copy may be mailed by ordinary mail. VICTOR AND VICTOR, LTD. Attorneys at Law 200 North LaSalle Street, Suite 2800 Chicago, Illinois 60601-1057 Telephone (312) 641-5330 Fax (312) 641-2231 Steven M. Victor Gayle L Victor Marvin M. Victor Of Counsel Deborah Korbas Legal Assistant AFFIDAVIT OF ACCOUNT JOHN A BOLLINGER is indebted to this Claimant in the amount of $ 1228.36, which includes all principal and interest now justly due and owing to Claimant from the Debtor pursuant to Account No. 1338420084. This is to certify that the above account is, upon information and belief of said affiant, true and accurate, and that the same is due and unpaid, and that all lawful and just offsets, payments, and credits have been allowed, and that a systematic record of such account has been kept by CITIBANK(SD)NA/TEXACO and that said affiant is authorized to make this affidavit. BY: Subscribed and sworn to before me, February 09, 2005 State of Illinois COli. nty Of.. C~OOk. ~.. / fl .J / ~,"J -;C ~'/ NOTARY PUBLIC ~rO'FPICIAL SEAL" Rosanne OalYe~ . p blic State of ,,"no IS Notary ':' 'on Ex'" 0811312.006 M" CommlSSl '" ..-v ., ....,........~ . ...- ~ HAROLD S. IRWIN. III. ESQ. ATTORNEY ID NO. 29920 64 SOUTH PITT STREET CARLISLE PA 17013 (717) 243-6090 ATTORNEY FOR ESTATE IN RE: ESTATE OF ,JOHN A. BOLLINGER, Deceased : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PEN~~YLVA",4 : ORPHAN'S COURT DIVISION ' " ; : NO. 21 - 04 - 1051 PETITION FOR SUBPOENA C,. 'I NOW comes Harold S. Irwin, III, attorney for the Estate of John A. Bollinger, and presents this petition for a subpoena, representing as follows: 1. Decedent, John A. Bollinger, died on November 5, 2004, having first made his last will and testament wherein he appointed his sister, Arlene S. Kohr, as his executrix. 2. The Register of Wills of Cumberland County, Pennsylvania, after receipt of a petition filed by Arlene S. Kohr to probate this will, appointed her to be executrix of the estate. 3. The executrix has retained the services of Harold S. Irwin, III, Esquire, Irwin Law Office, 64 South Hanover Street, Carlisle, Pennsylvania 17013, to represent the interests of the estate, to value and liquidate the assets of the estate, to pay the expenses of administration of the estate and claims against it and to distribute any remaining assets to the beneficiaries provided under the will. 4. In the course of the performance of these duties, the attorney has discovered that at the time of his death the decedent was the owner of a certain civil service retirement a~count which is a taxable, though nonprobate, asset of the estate from which his designated beneficiaries are entitled a death benefit. 5. After reviewing of the Designation of beneficiary form on file with the Civil Service Retirement System, the executor believes and therefore avers that the designation thereon is the result either of a forgery or of fraud and has been seeking to determine the witnesses' to the execution thereof by the decedent or another person or persons. Copies of the September 3, 2004 and October 16, 2004 beneficiary designation forms are attached hereto as Exhibit "A" and "B" and incorporated herein by reference. See also the attorney's February 16, 2005 letter attached as Exhibit "C" and incorporated herein by reference. 6. Furthermore, because it is necessary to obtain information regarding the value of the death benefit as of the date of decedent's death in order to properly complete an inheritance tax return the attorney has requested a statement from the Civil Service Retirement System as to such value. 7. On February 17, 2005, the Office of Personnel Management, Retirement Operations Center, sent a letter to the attorney for the estate indicating that under Federal Regulations, it would require a subpoena for the release of these documents and information. See letter attached at Exhibit "D" and incorporated herein by reference. 8. On February 28, 2005, the attorney for the estate obtained a subpoena from the Cumberland County Register of Wills, Glenda Farner Strasbaugh, directing that the Office of personnel Management, Retirement Operations Center, produce the following: All information regarding the civil service retirement account for John A. Bollinger. (SSN: 175-45-3251). including all supporting documentation, all beneficiary designations, a statement regarding the value of said account as of November 5, 2004, a statement regarding the death benefit applicable to said account, the manner in which said account or accounts may be liquidated and or death benefits may be obtained, as well as any other information or documentation for any and all other employee benefit programs to which his estate or other beneficiaries may be entitled. See a copy of the subpoena attached at Exhibit "E" and incorporated herein by reference. 9. On that same date, the attorney for the estate sent said subpoena to Marilyn Smith of the Office of personnel Management, Retirement Operations Center, by certified mail demanding the production of the documents and information as provided in the subpoena. See letter of February 28, 2005 attached as Exhibit "F" and incorporated herein by reference. 1 O. Said subpoena and letter was received by said office on March 4, 2005, as confirmed by the certified mail receipt attached hereto as Exhibit "G" and incorporated herein by reference. 11. On March 9, 2005, Bonnie Smith, of the same civil service office, wrote a letter to the attorney for the estate claiming that the subpoena issued and served upon the Office of Personnel Management does not comply with Federal Regulations because the subpoena is not signed by a judge. See March 9, 2005 letter attached as Exhibit "H" and incorporated herein by reference. 12. The inability to investigate the execution of the designation of beneficiary form and to obtain information regarding the value of the death benefit of this asset is preventing the executor and attorney for the estate from properly performing their duties and obligations with respect to the administration of this estate. 13. Furthermore, this situation jeopardizes the proper distribution of benefits in accordance with the proper wishes of the decedent. 14. Lastly, decedent died on November 5, 2004 and these benefits have still not been paid. This situation unjustly denies to the beneficiaries their possession of the death benefit proceeds in a timely manner and have caused unnecessary and inappropriate delay and expense in the administration of this estate. WHEREFORE, the attorney for the Estate of John A. Bollinger respectfully requests that this Honorable Court issue a subpoena directing that the Office of personnel Management, Retirement Operations Center, produce the documents and information referred to above and direct it not to release to any beneficiary the proceeds of the subject retirement account death benefit until authorized to do so by the attorney for the estate or further Order of this Court. IRWIN LAW OFFICE March 14, 2005 64 South Pitt Street Carlisle, PA 17013 717 -243-6090 VERIFICATION I, Harold S. Irwin, III, hereby certify that I am the attorney for the Estate of John A. Bollinger, deceased, that I have personal knowledge of the facts contained in the foregoing petition and that the facts stated in the petition are true and correct to the best of my knowledge, information and belief. I understand that false statements made herein are subject to the penalties of 18 Pa.C.S.A. Section 4094, relating to unsworn falsification to authorities. 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"- ~~ ~:::E oB: ,... o ~ cO o co N II> :0 '" V) :J V) C .g 'U Ql V) :J o '5 Ql a: o \' o co N ..,. t'i co 8 6 ~ ,... z CI) z d a-.- -r C).. i \.....J .. Form appr< OMB No. 3206-( Civil SeJVice Retirement System Designation of Beneficiary Civil Service Retirement System An employee Retired or an applicant for retirement to you. Former employee eligible for retirement in the future Department or agency in which presently employed (or former department or agency); Department or agency Bureau Division Social Security Number , .,off ~3 2 5' If you are retired. give your claim number. CSA Location (city. state and ZIP code) Oo.r1 '\ l) J 0/" M.."""~\..l:\""'k ~~....r I. the person identified above. designate the beneficiary or beneficiaries named below to receive any lump-sum benefit which may become payable under the Civil Service Retirement System (CSRS) after my death. I understand that this designation of benefICiary will not affect the rights of any survivors who may qualify for annuity benefits after my death. cancels at\y previous designation of beneficiary. and remains in effect until I cancel it h, writing or I receive payment before retirement of all the monies to my (lredit in the Civil Service Retirement and Disability Fund. I direct. unless otherwise indicated below. that if more than one is named. the share of any beneficiary who may predecease me r who ma) be disqualified for any other reason shall be distributed equally among the stated beneficiaries or entirely to the survivor. If none of the beneficiaries are alive and eligible to receive payment when a lump sum becomes payable, this designation is void and payment will be made according to the order 01 precedence set by law. .. t~i'''r I.. ,;~:; f f' .,}/" ;l"UO; ,,"{ i1: d;,U';U ',;" {:~.' ::'-Ju:, t',~,,~;i:ut/)/'::" ljKI tift "~:"'~i:ll'~"''''' in' /Yn,^1' ! ~f ~;t:~ ~.~ fi~~fR~} ~;,)...~".:.."tY. First name, middle initial, and last name of each beneficiary 0 Address (including ZIP code) of each beneficiary 49 Relationship to you 0 Share to be paid to each beneficiary #f ~ ;!." ~I Oil I( C.r 17"1 J 131"6 /4~(' r;ol ~~ r'l!'....~ yC7 L" 2." " 11.1( No- rr /7/6f 5ig~ "JF""'- -.1""......1"'...' 'C..VlI' QUUIC';:J;::':)U URn we can return ( ; t 1 Your designation is not effective until OPM receives and certifies it. Mail both copies of your designation of beneficiary to: U.S. Office of Personnel Management Retirement Operations Center P.O. Box 45 BOV:6~:~1f47-ro~ 1 J L .... ~ U.S. Office of Personnel Management 5 CFR 831 NSN 7540-00-634-4260 Part 1 . Original Standard Form 2808 Revised February 1999 Previous editions are usable .. ....-- .. " 2f\08-1Q,9. .. .. .. .. .. .. .. .. . .. .. .. . ...... .. .. .. .. .. .. .. .. .. ... . .. .. .. .. " .. . .. .. .. . .. .. .. .. .. '"' . ~ .. . " .. .' ., .. .. .. .. HAROLD S. IRWIN, III IRWIN LAW OFFICE 64 SOUTH PITT STREET CARLISLE, PENNSYLVANIA 17013 www.irwinlawoffice.com e-mail: irwinlaw@earthlink.net 717-243-6090 PHONE 717-243-9200 FACSIMILE RHONDA S. IRWIN ROBERT D. STAMBAUGH PARALEGALS February 16,2005 CAROL TOTH OFFICE OF PERS MGMT RETIREMENT OPS CTR BOYERS PA 16017 RE: Estate of John A. Bollinger Dear Ms. Toth: I represent Arlene Kohr, executrix of this estate. As you know, it has come to her attention that the last change of beneficiary form that you received from Mr. Bollinger may have been forged or that his signature may have been obtained from him by his brother at a time when he was not competent to execute a legal document. It is important that we have an opportunity to examine the entire form, including those who are purported to have witnessed the execution of the document, so that we can interview them about the circumstances surrounding its execution. If you require some other documentation before releasing this information, please advise immediately. We are serious about the implications of your office making a distribution without verifying the authenticity of this beneficiary form or the capacity of Mr. Bollinger to sign it. We will take further action if this information is not released, or if your office makes an inappropriate distribution . ~0~~ ... Harold S. Irwin, (II / V United States Office of Personnel Management Retirement Operations Center PO Box 45 Boyers, Pennsylvania 16017 Irwin Law Office 64 South Pitt St Carlisle P A 17013 February 17,2005 John A Bollinger Date of birth SS# CSF Dear SirlMadam: This is in reply to your recent inquiry. We are governed by the federal rules and regulations. According to the rules and regulations under Title 5 and The Code of Federal Regulations, you must get a subpoena duces tecum for us to release any records on the estate of John A Bollinger. Upon receipt of this information, we will submit the subpoena duces tecum and the letter from you to our subpoena employees for processmg. If our office can be of further assistance, please contact us again. Sincerely, :Marilyn Smitn. Marilyn Smith Legal Administrative Specialist 1--888--767--6738 Fc29j/ ils COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND IN RE: ESTATE OF .JOHN A. BOLLINGER, Deceased : FILE NO. 21 - 04 -1051 SUBPOENA TO PRODUCE DOCUMENTS OR THINGS FOR DISCOVERY PURSUANT TO RULE 4009.22 TO: OFFICE OF PERSONNEL MANA~EMENT RETIREMENT OPERATIONS CENTER PO BOX 45 BOYERS PA 16017 Within twenty (20) days after service of this subpoena, you are ordered by the court to produce the following document or things: All information regarding the civil service retirement account for John A. Bollinger, (SSN: 175-45-3251), including all supporting documentation, all beneficiary designations, a statement regarding the value of said account as of November 5, 2004, a statement regarding the death benefit applicable to said account, the manner in which said account or accounts may be liquidated and or death benefits may be obtained, as well as any other information or documentation for any and all other employee benefit programs to which his estate or other beneficiaries may be entitled at IRWIN LAW OFFICE, 64 SOUTH PITT STREET, CARLISLE, PA 17013. You may either deliver or mail legible copies of the documents or produce things requested by this subpoena, together with the certificate of compliance, to the party making this request at the address listed above. You have the right to seek in advance the reasonable cost of preparing the copies or producing things sought. If you fail to produce the documents or things required by this subpoena within twenty (20) days after its service, the party serving this subpoena may seek a court order compelling you to comply with it. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLOWING PERSON: HAROLD S. IRWIN, III, ESQUIRE 64 SOUTH PITT STREET CARLISLE PA 17013 717-243-6090 SUPREME COURT 10 NO 29920 ATTORNEY FOR ESTATE Date: s:(3~~~rt rL -fANm~~o;Uly HAROLD S. IRWIN, III IRWIN LAW OFFICE 64 SOUTH PITT STREET CARLISLE, PENNSYLVANIA 17013 www.irwinlawoffice.com e-mail: irwinlaw@earthlink.net 717-243-6090 PHONE 717-243-9200 FACSIMILE RHONDA S. IRWIN ROBERT D. STAMBAUGH PARAlEGALS February 28, 2005 MARILYN SMITH OFFICE OF PERSONNEL MGMT RETIREMENT OPERATIONS CTR PO BOX 45 BOYERS PA 16017 RE: Estate of John A. Bollinger SSN: 175 - 48 - 3251 Dear Ms. Smith: Thank you for your letter of February 17, 2005 in which youer indicated that your office requires a subpoena for the information requested. Enclosed for service upon you is a subpoena requiring the production of the following: All information regarding the civil service retirement account for John A. Bollinger, (SSN: 175-45- 3251), including all supporting documentation, all beneficiary designations, a statement regarding the value of said account as of November 5, 2004, a statement regarding the death benefit applicable to said account, the manner in which said account or accounts may be liquidated and or death benefits may be obtained, as well as any other information or documentation for any and all other employee benefit programs to which his estate or other beneficiaries may be entitled. Please provide this information now without further delay. The cautions outlined in my letter of February 16, 2005 (copy enclosed) remain in effect. /VerY7truly yours, \~U~ 'c_ Harold S. I~ <)a i'I [ 5""17- $ see~ 'l1 ellBJsod retOol (PGJrnbeH IUUWllSlOP\l3) ee~ NeAllllO P9lOl4SeH 9JllH 5LJ - I (P8JrnbeH lU9W9ll.lOllU3) ~w~ ~ id9fOllH WIIjllH or'l ., ee~ P9!lIlJIlO 0'- S e6Blsod I 3Sn 1VI::>I::I::I0' I . . .. . . . . .. . (pap!1I0Jd a6eJallo::J a:JueJnsuf oN :,{fUO I!ew :J!lsawoa) .ldl3J3H C'!l11"1/\I a31.::11.lH3J 'aa:>!^.Ias lE!lSOd "S'n --.J CI CI l.1J l.1J I::-' I::-' CI CI CI CI .r: In --.J --.J In .r: --.J I::-' ...D United States Office of Personnel~anageDlent P.Q,Box45 Boyers, PA 16017 Mar, 09, 2005 E050680002 Bollinger, John A Irwin Law Office 64 S, Pitt Street Carlisle, PAl 7013 Dear Mr, Irwin: This is in response to your request for information concerning the above named individual's benefits available through the Federal retirement system, The Privacy Act of 1974, as amended, 5 U,S,C. ~552a, does not permit us to disclose the information requested in your subpoena, The Office of Personnel Management will make disclosures in response to a subpoena where the Government is a party to the judicial or administrative proceeding, In those situations where the Government is not a party to the proceeding, records may be disclosed if a iudge has actually signed the subpoena, We will also release information on the basis of the individual's written consent. The subpoena you submitted does not meet the standards of 5 U.S,C, ~552a(b )(11), which authorizes disclosure of information "pursuant to the order of a court of competent jurisdiction," because it is not signed by a judge of such court, If we are served with an order that does meet that standard, please send it to: Office of Personnel Management Retirement Operations Center Po Box 45 ATTN: Subpoenas <STOP> Boyers, P A 16017 If, instead, you wish to provide a signed release from the individual that specifically details the records you need, it may be sent to: Office of Personnel Management p, 0, Box 45 Boyers, PA 16017 Attn: Raylene Ellenberger <STOP> The procedures applicable to the issuance of subpoenas in most States do not involve review by a judge. However, with respect to Federal records, our counsel determined in 1992 that if we honored a subpoena that did not qualify as a court order (i.e., because it was issued without the review of a judge), that it would be a violation of the Privacy Act as interpreted by the V. S. Court of Appeals for the District of Columbia Circuit. See Doe v. Stephens. 851 F2d 1457 (D.C. Cir. 1988). Although this caused difficulties in many jurisdictions, OPM determined that to comply with the Privacy Act, we had to amend our regulations (5 CFR 297.402) and routine uses applicable to release of information from all our systems of records to require an order or subpoena signed by a judge. Accordingly, we had no choice but to discontinue the practice of accepting attomey- issued or clerk-issued subpoenas. We are enclosing a copy of your subpoena. I hope you find this information helpful. Sincerely, Bonnie Smith Customer Service Representative Retirement Operations Center 1(888)767-6738 Enclosures HAROLD S. IRWIN, III, ESQ. ATTORNEY ID NO.'29920 64 SOUTH PITT STREET CARLISLE PA 17013 (717) 243-6090 ATTORNEY FOR ESTATE MAR 1 4 2005 -r:D IN RE: ESTATE OF .JOHN A. BOLLINGER, Deceased : IN THE COURT OF COMMON PLEAS OF :,CUMBERLAND COUNTY, PENNSYLVANIA : ORPHAN'S COURT DMSION ,.;: : , ,--. "':'..:::.~ : NO. 21 - 04 - 1051 ORDER NOW, this l""- day of March, 2005, upon consideration of the petition oft-l~rold s;: , '-.0 Irwin, III, Esquire, attorney for the Estate of John A. Bollinger, it is hereby ORDERED and DECREED that the Office of Personnel Management, Retirement Operation Center, P.O. Box 45, Boyers, PA 16017, shall produce the following documents, information or other things within TEN days of the date of this Order: , All information regarding the civil service retirement account for John A. Bollinger, (SSN: 175-45-3251), including all supporting documentation, all beneficiary designations, a statement regarding the value of said account as of November 5, 2004, a statement regarding the death benefit applicable to said account, the manner in which said account or accounts may be liquidated and or death benefits may be obtained, as well as any other information or documentation for any and all other employee benefit programs to which his estate or other beneficiaries may be entitled. Such documentation and information shall be produced at the office of the attorney for the estate, IRWIN LAW OFFICE, 64 SOUTH PITT STREET, CARLISLE, PA 17013, either by mail or in person. Further, the Office of Personnel Management, Retirement Operations Center, is directed not to release to any beneficiary the proceeds of the 1ect retirement account death benefit until authorized to do so by the attorney for tate or further Order of this Court. J. 3\ \'5 \X\a:,\ e1 -\0 cJI? \f\o-.{'\, (\ 5~~\~~ \~\C\d. lt~\ 1\ \\ \ / \\~ . COMMONWEALTH OF PENNSYLVANIA COURT OF COMMON PLEAS OF CUMBERLAND COUNTY ORPHANS' COURT DIVISION NOTICE OF CLAIM In Re: The Estate of: JOHN A BOLLINGER Deceased Court File No: 21041051 TO: THE CLERK OF THE ORPHANS' COURT DIVISION: Notice of claim by creditor, Pursuant to Section 3532(b)(2) of the Probate, Estates, and Fiduciaries Code, 20 PA.C.S.A. S3532(b)(2). CITICORP CREDIT SERVICES, INC. (USA) 1) Claimant's name: C/O BALOGH BECKER LTD, 4150 OLSON MEMORIAL 2) Claimant's address: HWY #200 MINNEAPOLIS, MN 55422 866-234-0512 3) Creditor listed below is the owner and holder of a claim in the amount of $ 1646.43 4) The facts upon which this claim is based: This claim is based on an account for credit evidenced by the attached Affidavit of Account Stated. 5) Decedent's address: 48 SCARSDALE DR CAMP Hill, PA 17011 6) Date of Death: 11/05/04 7) That the claim arose prior to the death of the decedent on or about 8) That the claim is secured by On behalf of the claimant, I do solemnly declare and affirm under the penalties of perjury that they Information and representations made herein are true and correct to the best of my owl dge, information and belief. Dated: Inske/Thersia Lee ille Dean, Atty-in-Fact Written notice of claim was given to Personal Representative and/or his/her counsel as stated below: ARLENE KOHR Name 2466 MERCER ST (::rl Address HARRISBURG, PA 17104 City /Statef, i p D) ailed ("',, (Ii U:' IN RE ESTATE OF: JOHN A BOLLINGER AFFIDAVIT OF ACCOUNT The undersigned, being first duly sworn deposes and states the follows: I. Your Affiant is authorized by the Claimant as its Attorney-In-Fact to make this Affidavit. 2. Your Affiant has reviewed the account records of the Claimant with respect to the decedent. Your Affiant is familiar with these records and accounts and reviews them as a regular part of his/her duties. 3. The Decedent purchased merchandise in the amount of$I646.43 account number 6011766303459739 evidenced by 4. The unpaid balance does not include any post-death late payment charges, accrued interest, collection costs or attorney's fees. Further your affiant sayeth not BALOGH BECKER, LTD. BY:~ Attorneys-in-Fact: ~ ______ Chelsea A. Whitley _ Angela M. Horn ~ Mary Ellen Weeman _ Thersia O. Lee_ Chad J. Bolinske Kamille R. Dean 4150 Olson Memorial Highway, Suite 200 Minneapolis, MN 55422-4811 CO) Subscribed and sworn before me This ~h(( day Of~' 2005. NO~~ ~ ti- :'~"i. r -.,..., "I :"\~:; (,,,, l..f,) e.'t^~. PAIGE LANNON ELLIOTT ~-.,~ NOTARY PUBLIC - MINNESOTA ; 'l~ My Commission Ekpll8S Jan. 31,2009 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES PO Box 280601 HARRISBURG, PA 17128-0601 Telephone November 3, 2005 717 -783-6893 Rhonda S. Irwin 64 S. Pitt St. Carlisle, Pa. 17013 Re: Estate of John A. Bollinger File Number 2104-1051 Dear Ms. Irwin: This is in response to your letter of October 28, 2005, concerning the Inheritance Tax return due in regards to the above referenced estate. Since it is apparent that you will be unable to file a tax return in the near future, the estate record will be placed in an informal hold status for an additional period of six (6) months so that the Department will initiate no enforcement activity. At the end of that period we would ask that you contact us to provide an updated status for our file. Thank you for your cooperation and if I may be of any further assistance, please feel free to contact this office. ,--,J ure u mer ''''"'- I heritance Tax Division Bureau of Individual Taxes E-Maillfulmer@state.pa.us ~ M C ! c_ c: C RK. REV-1500 EX + (6-00) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT_ 280601 HARRISBURG, PA 17128-0601 DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) I- Z W C W () W C BOLLINGER, JOHN A. DATE OF DEATH (MM-DD-Year) REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER 2 1 -0 4 1 0 5 1 COuNTYCOOE --vEA~ - - NuMBER- - SOCIAL SECURITY NUMBER DATE OF BIRTH (MM-DD-Year) 75- 4 8 - 3 2 5 1 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 11/05/2004 10/24/1955 (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) W l- x: :$lI) U 0:: x: wg;u J:0::3 UD-llI D- c:( !Xl 1_ Original Return o 4. Limited Estate !Xl 6. Decedent Died Testate (Attach copy 01 Will) o 9. Litigation Proceeds Received SOCIAL SECURITY NUMBER o 2_ Supplemental Retum o 4a. Future Interest Compromise (date of death after 12-12-82) o 7_ Decedent Maintained a Living Trust (Attach copy oITrust) D 10_ Spousal Poverty Credit (date oldealf1 between 12-31-91 and 1-1-95) o 3. Remainder Return (date of death priorta 12-13-82) o 5. Federal Estate Tax Return Required _ 8. Total Number of Safe Deposit Boxes o 11. Election to tax under Sec. 9113(A) (AttachSch 0) I- Z W o Z o D- lI) W 0:: 0:: o U THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCEANDCONFIDENTIAETAXINFORMATIONSHOULD BE DIRECTED TO: NAME COMPLETE MAILING ADDRESS HAROLD S. IRWIN, III 64 SOUTH PITT STREET FIRM NAME (If Applicable) IRWIN LAW OFFICE CARLISLE PA 17013 TELEPHONE NUMBER 717-243-6090 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnership or Sole.Proprietorship (3) 4. Mortgages & Notes Receivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) (Schedule E) 6. Jointly Owned Property (Schedule F) (6) o Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non.Probate Property (7) (Schedule G or L) 8. Total Gross Assets (total Lines 1.7) 9. Funeral Expenses & Administrative 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 rninus Line 11) z o i= < ...J ::> t: a. < () w 0::: 0.00. J 0.06-.: 8 t__.: :::;c:' 0.00 '~r: Q '~- ", :?; ~ 0.00 ,-)- :C;'. :-'~ :--. ~' .- '. j,) 13,198.8~ /':>"'n ~~ ':.j - --4 O.OQJ I"..;:). (_::..r-. ];::t. ~.T~! ;;'0 1".) v (. ,~; S'~:'~ - -'''1 Co) ,-" ,) ,-'") ....'1 f'..> c, C-. 56,072.81 (8) 69,271.70 7,776.77 37,922.69 (11) (12) (13) 45,699.46 23,572.24 0.00 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) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES z o i= < I- ::> a. ::!: o () >< < I- 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 collateral rate 19. Tax Due (14) 23,572.24 0.00 X _(15) 0.00 0.00 X _(16) 0.00 22,517.15 X .12 (17) 2,702.06 1,352.50 X .15 (18) 202.88 (19) 2,904.94 20. D CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT > > BE SURE TO ANSWER ALL QUESTIONS ON.REVERSESIDE AND RECHECK MATH < << Decedent's Complete Address: STREET ADDRESS 48 SCARSDALE DRIVE CITY 1 STATE PA I ZIP 17011 CAMP Hill Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1 ) 2,904.94 Total Credits (A + B + C) (2) 0.00 3. Interest/Penalty if applicable 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 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) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WILLS, AGENT 0.00 0.00 2,904.94 2,904.94 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes a. retain the use or income of the property transferred; ........................................................................... D b. retain the right to designate who shall use the property transferred or its income; ........................................ D c. retain a reversionary interest; or ...................................................................................................... D d. receive the promise for life of either payments, benefits or care? ............................................................. D 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration?.............................................................................................. D 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ................. D 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which . b f" d' t' ? I)(l contains a ene IClary eSlgna Ion. ....................................................................................................... ~ No [K] [K] [K] [K] [K] [K] D 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 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 tnue, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SlGNATU1E OF PERSON ~ESf9NSIBLE FOR FILING RETURN . o.ATE .' ,~L'PAie- -J4Z},~ [j- Y --()tLJ ADDRESS 2466 Mercer Street Harrisbur PA F PREPARER OTHER THAN PRESENTATIVE ._~---- PA 17013 6(. 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. 99116 (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. 99116 (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 twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, Jr a stepparent of the child is 0% [72 P.S. s9116(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. S9116(1.2) [72 P.S. s9116(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. S9116(a)(1.3)]. A sibling is defined, under Section 9102, as an ndividual who has at least one parent in common with the decedent, whether by blood or adoption. KI::V-15UZ 1::.". + (0-\)13) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER BOLLINGER. JOHN A. 21 04 1051 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real properly which is iointlv-owned with riaht of survivorship must be disclosed on Schedule F. SCHEDULE A REAL ESTATE ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH NONE 0.00 TOT AL (Also enter on line 1, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 0.00 ,{EV-1503 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF BOLLINGER. JOHN A. FILE NUMBER 21 04 All property jointly-owned with right of survivorship must be disclosed on Schedule F. 1051 DESCRIPTION VALUE AT DATE OF DEATH ITEM NUMBER 1. NONE 0.00 TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 0.00 ~EV-1504 EX + (6-98) '* COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C ClOSEl V-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF BOLLINGER. JOHN A. FILE NUMBER 21 04 1051 Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH NONE 0.00 TOTAL (Also enter on line 3, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 0.00 REV-1507 EX + (6-98) SCHEDULE D MORTGAGES & NOTES RECEIV ABLE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF BOLLINGER. JOHN A. FILE NUMBER 21 04 All property jointly-owned with the right of survivorship must be disclosed on Schedule F. 1051 DESCRIPTION VALUE AT DATE OF DEATH ITEM NUMBER 1. NONE 0.00 TOTAL (Also enter on line 4, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 0.00 REV-150B EX + (6-9B) . SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER 21 04 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ESTATE OF BOLLINGER. JOHN A. 1051 ITEM NUMBER 1. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. DESCRIPTION VALUE AT DATE OF DEATH 462.86 CAROLE M. BOLLINGER ESTATE Distribution from mother's estate SW ANSON Rebate 1.69 CAPITAL ONE Refunds 24.59 OFFICE MAX Rebate 30.00 COMMONWEALTH OF PENNSYLVANIA Department of Revenue Refund MEMBERS 1 ST FEDERAL CREDIT UNION Close Accounts Exhibit B M & T BANK Refund 10.00 11,277.71 39.54 1993 FORD AEROSTAR MINIVAN Kelley Blue Book - Average of Private Party and Trade-in Values Exhibit C Computer (older) 1,132.50 25.00 Digital Cameram (older, used) 150.00 Printers (older, used) 35.00 DVD Sets (2, Lord of the Rings; Babylon Five) 10.00 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 13,198.89 REV-1509 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF BOLLINGER. JOHN A FILE NUMBER 21 04 1051 If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. B c JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL EST ATE. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. NONE 0.00 0.00 TOTAL (Also enter on line 6, Recapitulation) $ 0.00 (If more space is needed, insert additional sheets of the same size) REV-1510 EX + (6-98) SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF BOLLINGER. JOHN A. FILE NUMBER 21 04 1051 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE. THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECO'S EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER. ATTACH A COPY OFTHE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST VALUE (IF APPlICABLEI 1. CIVIL SERVICE RETIREMENT SYSTEM 53,046.42 100. 53,046.42 Survivor or Death benefit payable to Arlene S. Kohr and James Bollinger Exhibit D 2. THRIFT SAVINGS PLAN 3,026.39 100. 3,026.39 Death Benefit payable to Arlene S. Kohr Exhibit E TOTAL (Also enter on line 7 Recapitulation) $ 56,072.81 (If more space is needed, insert additional sheets of the same size) REV-1511 I:X + (12-tltl) SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF BOLLINGER. JOHN A. FILE NUMBER 21 04 1051 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. AUER MEMORIAL HOME and CREMATION SERVICES, INC. 1,949.77 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name 01 Personal Representative (s) Social Security Number(s)/EIN Number 01 Personal Representative(s) Street Address City State Zip Year(s) Commission Paid: 2. Attorney Fees IRWIN LAW OFFICE 4,500.00 3. Family Exemption: (II decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship 01 Claimant to Decedent 4. Probate Fees CUMBERLAND COUNTY REGISTER OF WILLS 81.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. CUMBERLAND COUNTY REGISTER OF WILLS - Filing Costs 30.00 8. RENT FOR RESIDENCE - 48 Scarsdale Drive, Camp Hill,PA 17011 1,190.00 9. BONNIE K. MILLER, TREASURER - Personal Taxes 11.00 10. CUMBERLAND COUNTY ORPHANS COURT - Petition 15.00 TOTAL (Also enter on line 9, Recapitulation) $ 7,776.77 (II more space is needed, insert additional sheets 01 the same size) REV-1512 EX + (6-98) . SCHEDULE. DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF BOLLINGER. JOHN A. FILE NUMBER 21 04 1051 Include unreimbursed medical expenses. ITEM NUMBER DESCRIPTION 1. COMCAST CABLE Utility Bill VALUE AT DATE OF DEATH 94.20 2. AT&T and VERIZON Utility Bills 121.45 3. PENNA-AMERICAN WATER COMPANY Utility Bill 25.27 4 ANDREWS & PATEL ASSOCIATES, P.C. # 20855 Medical Care 882.38 5. ASSOCIATED CARDIOLOGISTS # 207439 11.71 6. FAMILY HOME MEDICAL, INC. # -1 BOLLJ 15.95 7. CONNOR-RICH ASSOCIATES # 26798 Medical Care 294.00 8. HERITAGE MEDICAL GROUP, LLP # 91299 89.50 9. GENZYME GENETICS # NY-04-058603 162.72 10. HEALTHSOUTH REHABILITATION HOSPITAL#213951 14.84 11. HOLY SPIRIT HOSPITAL # 23784887,23935414,23963879,24237927 450.88 12. PENNSYLVANIA GASTROENTEROLOGY CONSULTANTS # 102118 38.00 13. PENNSYLVANIA NEUROLOGICAL ASSOCIATES LTD. # 45719 20.00 14. PRISM # 037894 Medical Care 184.90 15. PINNACLE HEALTH HOME CARE # 128809 169.92 Ilf mn... o::nRr.P. is needed. insert additional sheels of the same size) ~ontinuation of REV-1500 Inheritance Tax Return Resident Decedent BOLLINGER, JOHN A. Decedent's Name 21 04 1051 File Number Schedule I - Debts of Decedent, Mortgage Liabilities, & Liens ITEM NUMBER 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. DESCRIPTION PULMONARY & CRITICAL CARE MEDICAL ASSOCIATES, P.C. # 43326 AMOUNT 66.00 QUANTUM IMAGING & THERAPEUTIC # 147120A93 43.40 WEST SHORE ANESTHESIA # 60141 27.30 WELLS FARGO FINANCIAL RETAIL SERVICES # 1029006/0699-090488 Retail Account 1,360.96 CITICORP CREDIT SERVICES, INC. USA#2041051 Retail Collection - Gateway 1,611.43 VICTOR AND VICTOR, LTD. # 1338420084 Citibank (SD) NAlTexaco Retail Collection 1,228.36 NCO NCO FINANCIAL SYSTEMS INC # 1523003173427440 Circuit City Retail Collection 1,015.79 MERCANTILE ADJUSTMENT BUREAU, LLC # 5484009469181 Sears Retail Collection 6,240.96 CLIENT SERVICES, INC. # 460768 US BANK Retail Collection 2,806.69 HAYT, HAYT & LANDAU # 20310361 Bryn Mawr Stereo Retail Collection 1,372.16 WORKING ASSETS # 5487090050022807 Credit Card 6,285.43 GULF OIL CORPORATION # 5487795000689394 Credit Card 2,665.06 GECAF # 6905074625905745 Credit Card 2,420.49 LOWE'S # 81602216082285 Credit Card 1,986.58 DIAL NATIONAL BANK Retail Collection 2,246.29 Continuation of REV-1500 Inheritance Tax Return Resident Decedent BOLLINGER, JOHN A. Decedent's Name Page 2 21 04 1051 File Number Schedule I - Debts of Decedent, Mortgage Liabilities, & Liens ITEM NUMBER 31. DESCRIPTION AMOUNT 3,963.92 FLEET FINAL Retail Collection 32. HERITAGE MEDICAL GROUP LAB 2.50 33. QUEST DIAGNOSTICS # 3063097162 3.65 GRAND TOTAL SCHEDULE I ~ ':l.7 O?? ':::0 Rev.""".,.. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARIES FILE NUMBER BOlLlN( ER JOHN A. 21 04 1051 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I. TAXABLE DISTRIBUTIONS pnclude outright spousal distributions, and transfers under Sec. 9116 (a)(1.2)] 1. ALlSHA K. KOHR Collateral 2466 Mercer Street 1,157.50 Harrisburg, PA 17104 2. RALPH KOHR Collateral 2823 Croyden Street 185.00 Harrisburg, PA 17104 3. HOllY DAVIS Collateral 2823 Croyden Street 5.00 Harrisburg, PA 17104 4. JAKE GROVE Collateral 423 Walnut Street 5.00 Harrisburg, PA 17101 5. ARLENE S. KOHR Sibling 2466 Mercer Street 100% Residue Harrisburg, PA 17104 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. NONE 0.00 B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. NONE 0.00 TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 0.00 __-.J_..J ~___........ _...J..J!.I..!___I_L.__"_ _L...l..._ ____ _:__\ LAST WILL AND TESTAMENT I, JOHN A. BOLLINGER, of 48 Scarsdale Drive, Camp Hill, Cumberland County, Pennsylvania 17011, do hereby make, publish and declare this to be my last will and testament, hereby revoking all wills heretofore made by me. 1. I direct my personal representative to pay all of my debts, funeral and administrative expenses as soon as convenient after my decease. I direct that all inheritance taxes imposed or payable by reason of my death and interest and penalties thereon with respect to all property, whether or not such property passes under this Will, shall be paid by my personal representative out of my estate. 2. I authorize and empower my personal representative to sell any realty and/or personalty owned by me at my death and not specifically devised or bequeathed herein, at public or private sale or sales and to give good and sufficient deeds and/or bills of sale therefore, in fee simple, as I could do if living. My representative is authorized and empowered to engage in any business in which I may be engaged at my death, for such period of time after my death as seems expedient to said representative. 3. I give, devise and bequeath all of my estate of whatever nature and wherever situate as follows: A. Any motor vehicle I may own at my death and my computer to my niece, Alisha K. Kohr; B. My digital camera and my printers to my nephew, Ralph Kohr; C. My Lord of the Rings DVD set to my friend, Holly Davis; D. My Babalon Five DVD set to my friend, Jake Grove; and all the E. 'Rest, residue and remainder to my sister, Arlene S. Kohr. 5. I nominate and appoint my sister, Arlene S. Kohr, to be the personal representative of my estate, to serve without bond. If she cannot or does not serve, then I appoint my niece, Alisha K. Kohr to be my substitute personal representative, also without bond. IN WITNESS WHEREOF, I have hereunto set my hand and seal this 29th day of October, 2004. ~' ~,~ JO~ A. BOLLI GER (SEAL) Signed, sealed, published and declared by the above-named person as and for a last will and testament, in our presence, who at said person's request, in said person's presence and in the presence of each other have hereunto set our names as subscribing witnesses. -. /7}\ /J)OlZ/&O d i;u< wn ) .) - r::~/~~~ L/ - ACKNOWLEDGMENT AND AFFIDA VIT WE, JOHN A. BOLLINGER, RHONDA S.IRWIN and CONSTANCE T. HESS, the testator and witnesses respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the testator signed and executed the instrument as his last will and that he had signed willingly, and that he executed it as his free and voluntary act for the purpose herein expressed, and that each of the witnesses, in the presence and hearing of the testator, signed the will as a witness and that to the best of their knowledge the testator was, at that time, eighteen years of age or older, of sound mind and under no constraint or undue influence. J~ , ~~ I /, \ I /., . j/ ,~ MloJyfft) d .?IVYlY7 RHONDA S. IRWIN (1)~A1/774~ CONSTANCE T. HESS STATE OF NEW YORK :55: COUNTY OF ERIE Subscribed, sworn to and acknowledged before me by JOHN A. BOLLINGER, the testator herein, and subscribed and sworn to before me by RHONDA S. IRWIN and CON~TA~~E T. HESS, witnesses, this 29Za:u~ 1,IOT{~.fU'\L=i'_"L Notary Public U i-L.;nC!LD s. !,RVvj/\i ',-:.t;RLlS~,E 5Cir~c}UGh. C:(}UNTy MY CC1~\..'1~j1l')::'\C\! FXP:P,ES DATE / ~I/ ~/o Ar- Checks and other items are received for deposit subject to the terms and conditions of this financial institution's account agreement. Deposits may not be available for immediate withdrawal. Orrstown Bank Shippensburg, PA 17257 I , '" /U UV- I ;.JV,J!U I..) IOt.;J~ ~ TOT OTHER SIDE LESS CASH REC'D TOTAL II Z I -:O:l ~:l ~ SO :lb-: ~OBOO 2BO ~II. ri:1 f.."ii -10]" II,', I =I 11 1Sl: f'\.-"'f!"I~I!l'" ;11 1;;11," "1"'''''''. =1;1""'1 ;1~C:l;11 lii=l -)Io11.i: l:tl "",",.. i;I;:fl;;l ;10]11 1II01ai :1'11-101," 11,',1 =IIi 1IIl: r'~""'lI:[o]lI:olcj;"I"/!I!"1 *1=1 1[,.;8:0] ;l(i: I ::!-"i:tl;;l=!"li I tv lSM~~~~~lI!~ P.O. Box 40 Mechanicsburg, Pennsylvania 17055 Issued By: Travelers Express Company, Inc. P.O. Box 9476. Minneapolis MN 55480 Drawee: Boston Safe Deposit & Trust Company Boston. MA 5-709/110 00 DATE 12/04/04 $11 PAY ** Ten Thousand Five Hundred Thirty-Five and 01/100 DOLLARS ** TO THE ORDER OF ESTATE OF JOHN BOLLINGER 64 SOUTH PITT STREET CARLISLE, P A. 17013 a Drawer: MEMBERS 1 ST FEDE /...-- II- II- ~ 0 5 :l ~ 5"- I: 0 ~ ~ 0 0 70 g 21: 0 ~ bOO ~ ~ :l 0 L. 7 B 2"- ~;: I !~th I -I" ~ J Ifd :4111 fj: r.~ 'fY ,; ~ (I., a B i;of[" r ., 1& lj'l' ';! It ~: ll'I' ":1 ~t2:J :11 ~ .i ~ J If. J ~..: l::e: ,. '{ Ii ~_I; I =I;: it] ~ ...el ;ttu: I =- t I. I Iii 11'11 ~ ~ 1111:" 1--....,11: {.] .'1 Ci ;J-' MIIf .,: J...""i ~ N"" =* 11;jJ I: I ~ "}:::II;I::f " I U J; I tv lSM~~~~~lI!~ P.O. Box 40 Mechanicsburg, Pennsylvania 17055 Issued By: Travelers Express Company, Inc. P.O. Box 9476. Minneapolis MN 55480 Drawee: Boston Safe Deposil & Trusl Company Boslon, MA 5-709/110 00 DATE 12/04/04 $74 PAY ** Seven Hundred FOliy- Two and 70/1 00 DOLLARS ** TO THE ORDER OF ESTATE OF JOHN BOLLiNGER 64 SOUTH PITT STREET CARLISLE, P A. 17013 OF Drawer: MEMBERS 1 ST FEDER TWO SIGNATURES REQUIRED FOR CH ~~ II- II- 1. 0 5 :) 1. :)11- I: 0 ~ ~ 0 0 70 g 21: 0 ~ bOO ~ l. :l 0 L. 7 B 2 II- DEPOSIT TICKET "d S Irwin "' ..... T A Account 1 DATE )(4!oc CURRENCY COIN ( / SZ- ~ TOT OTHER SIDE LESS CASH REC'D TOTAL ('I J2- S'V 60-1503/313 Checks and other items are received for deposit subject to the terms and conditions of this financial institution's account agreement. Deposits may not be available for immediate withdrawal. Orrstown Bank Shippensburg, PA 17257 I:O~.:i l.SO~bl: l. 08 0 0 28 0 l. II- 207 9/ .... ." "',......:! '-"'J".;': ;~.<:"';, '::.,Fr"";' ''',':,,':,;;::::':, ;:j:,~ ~.' :\:!-:,-::':;3,;X~';{> "ii;" c,'C,UBI:RTY";" LUMP SUM 03/23/2005 11:03:15 1 OF 2 RECORDS (' ~ CHECK ADDRESS: ARLENE S KOHR -2466 MERCER ST HARRISBURG PA 17104 DEC NME: BOLLINGER JOHN A CLAIM NUMBER: F2931475 A DEC SSN: 175483251 VOUCHER NUMBER: 50118 CHK RANGE: 2687880 DATE: 01/21/05 WAIVER ID: 6 ZIP-GEO CODE: 17104 PAYMENT CONTRIBUTIONS: INTEREST: FIT WITHHELD: CHECK AMOUNT: DATA 26,523.21 0.00 0.00 26,523.21 r PAYEE SSN: 179504803 CANCELLATION DATA DATE CANCELLED: 00/00/00 SCHEDULE NUMBER 000-0-000 REASON: DATE ENTERED IN NPPA: 00/00/00 PF1-RFLSMENU PF6-NEW RECORD PF7-PREV SCREEN PF12-1099 ADDR PF16-CANCELLATION UPDATE PAl-APPLICATION MENU PF8-NEXT SCRREN PA2-TERMINATE SESSION Fl'. r p.'n.oy, 1.11.... L", u~r" THRIFT SAVINGS PlAN Thrift Savings Plan National Finance Center P.O. Box 61500, New Orleans, LA 70161-1500 A-I -f- Ai-'L t- *****~ * ~ * * ARLENE, KOHR 2466 MERCER STREET HARRISBURG, PA 17104 02/04/2005 Dear Sir or Madam: A death benefit payment has been processed from the Thrift Savings Plan (TSP) account of: Participant's Name: BOLLINGER, JOHN Date of Payment: 02/04/2005 Total Amount of Payment: Minus Amount withheld: Net Amount Paid to You: Payment Method: Check ) $3,026039/A''Z. $1,302.64 $1,723.75 A-I The amount paid to you by check or direct deposit will be reported to the Internal Revenue Service on Form l099-R, Distributions from Pension, Annuities, Retirement or Profit Sharing Plan, IRAs, Insurance Contracts, etc. You will receive a copy of this form by January 31 of next year. If your address shown is not correct, please notify the TSP immediately. Materials mailed to an incorrect address may not reach you. Mail your address information to the address on the letterhead. If you have questions, call the ThriftLine number shown below. (Callers outside the United States and Canada should call (504) 255-8777.) The Service Office hours are Monday through Friday, 7 a.m. to 9 p.m. eastern time. You can also write to the Service Office. Please include your daytime telephone number and your entire Social Security number on all correspondence. Note: If you are a member of the uniformed services, do not provide your Defense Switched Network (DSN) telephone number. Web: www.tsp.gov ThriftLine: 1-TSP- YOU-FRST (1-877-968-3778) TDD: 1-TSP.THRIFT5 (1-877-847-4385) Notice: DC4051 06-19-2006 BOLLINGER 11-05-2004 21 04-1051 CUMBERLAND 101 APPEAL DATE: 08-18-2006 ( 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 9~!_~~9~~_!~}~_~}~~______~___~~!~!~_~Q~~~_~Q~!!Q~_~Q~_YQ~~-~~~Q~~~--~-------------------- REV-1547 EX AFP (03-05) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX JOHN A FILE NO. 21 04-1051 ACN 101 DATE 06-19-2006 TAX RETURN WAS: ( ) ACCEPTED AS FILED ( X) CHANGED SEE ATTACHED NOTICE ~BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION PO BOX 280601 HARRISBURG PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX ~-"APPRA1~EMERT';-ALLOWANCE OR DISALLOWANCE of DEbucTIONS AND ASSESSMENT OF TAX '-.... I ~ I:', \ DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN ....... n~ ':J /-...-, HAROLD S IRWIN III IRWIN LAW OFFICE 64 S PITT ST CARLISLE PA 17013 ESTATE OF BOLLINGER REV-1547 EX AFP (06-05) JOHN A 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) 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) &. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets (1) (2) (3) (4) (5) (&) (7) .00 .00 .00 .00 13.198.89 .00 .00 (8) APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adn. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governnental Bequests; Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax (9) (10) 7,776.77 37.922.69 lll) ll2) ll3) ll4) NOTE: To insure proper credit to your account, subnit the upper portion of this forn with your tax paynent. 13,198.89 45.699 46 32,500.57- .00 32,500.57- 14, 15 and/or 16, 17, 18 and 19 will returns assessed to date. NOTE: I~ an assessment was issued previously, lines re~lect ~igures that include the total o~ ALL ASSESSMENT OF TAX: 15. Anount of Line 14 at Spousal rate (15) 1&. Anount of Line 14 taxable at Lineal/Class A rate (1&) 17. Anount of Line 14 at Sibling rate (17) 18. Anount of Line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due .00 X 00 = .00 X 045= .00 X 12 = .00X15= ll9)= .00 .00 .00 .00 .00 TAX CREDITS: n...~..' ,,~~~.. . l+J AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 04-21-2006 CD006588 .00 2,904.94 TOTAL TAX CREDIT 2,904.94 BALANCE OF TAX DUE 2,904.94CR INTEREST AND PEN. .00 TOTAL DUE 2,904.94CR . 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.) ,(\ /' ~v REV-1470 EX (6-83' INHERITANCE TAX EXPLANATION OF CHANGES COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES PO Box 280601 HARRISBURG PA 17128-0601 DECEDENTS NAME FILE NUMBER John A. Bollinger REVIEWED BY ACN 2104-1051 101 Sheila Megonnell ITEM SCHEDULE NO. G 1 &2 EXPLANATION OF CHANGES Items #1 and #2 are not reportable items for Inheritance Tax purposes when the decedent has not reached the age of 59 % years at his date of death. ROW Page 1 REGISTER OF WILLS CUMBERLAND COUNTY, PENNSYLVANIA INVENTORY Estate of JOHN A. BOLLINGER No. 21 04 1051 , Deceased Date of Death 11/5/2004 Social Security No. 175483251 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 Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said inventory represents its fair value as of the date of the Decedent's death, and that Decedent owned no real estate outside the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory. I/We 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. Name of Attorney: HAROLD S. IRWIN, III 1.0. No.: 29920 Address: 64 SOUTH PITT STREET Perso~al Representative: /~ ~/nt- ~~j~ ARLENE S. KOHR Dated APRIL ,2006 CARLISLE PA 17013 Telephone: 717-243-6090 Description Value THRIFT SAVINGS PLAN Death benefit paid to Arlene S. Kohr 3,026.39 CIVIL SERVICE RETIREMENT CENTER Survivor death benefit payable to Arlene S. Kohr and James Bollinger 53,046.42 CAROLE M. BOLLINGER ESTATE Distribution from mother's estate 462.86 SWANSON Refund 1.69 CAPITAL ONE Refunds 24.59 OFFICE MAX Rebate \-11 ' ,VOl (II ,'.F' """'n'" l/G \~)'.) \..jj "<1 ['J tbju~' '_ '-wi ltJil08 S,NVHdtJO '0 \J~..r'lf'\ ::; /iuj ,) 30.00 Total (Attach Additional Sheets if necessary) S S :2 Wd 12 MdV 90Dl 69,271.70 NOTE: The Memorandum of real estate outsid~tljltl CommqnweaUh pf Pennsylvania may, at the election of the personal representative, include the value of each item, but such figures'stY6~ld:ndt bie.extended into the total of the Inventory. _I:.',. J(":tJ~.l(~ (-."'r- ir~,t :".'t." .~J _\..I__.~ '..!h \_\",:\jv'_~'~ RW-4 Continuation of Inventory JOHN A. BOLLINGER 21 04 1051 Paqe 1 Description of Inventory Description COMMONWEALTH OF PENNSYLVANIA Department of Revenue Refund Value 10.00 MEMBERS FIRST FEDERAL CREDIT UNION Bank Accounts 11,277.71 M & T BANK Refund 39.54 1993 FORD AEROSTAR MINIMAN KELLEY BLUE BOOK (Average Private Party I Trade-in Value) 1,132.50 OLD, OBSOLETE COMPUTER 25.00 OLDER, USED DIGITAL CAMERA 150.00 OLDER, USED COMPUTER PRINTERS 35.00 DVD USED SETS 10.00 Subtotal $ 12,679.75 69,271.70 Grand Total $ PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: IRWIN HAROLD Sill 64 SOUTH PITT STREET CARLISLE, PA 17013 nn____ fold ESTATE INFORMATION: SSN: 175-48-3251 FILE NUMBER: 2104-1051 DECEDENT NAME: BOLLINGER JOHN A DATE OF PAYMENT: 04/21/2006 POSTMARK DATE: 04/21/2006 COUNTY: CUMBERLAND DATE OF DEATH: 11/05/2004 REV-1162 EX(11-96) NO. CD 006588 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $2,904.94 I I I I I I I I TOTAL AMOUNT PAID: $2,904.94 REMARKS: CHECK# 10362 SEAL INITIALS: MG RECEIVED BY: ~~r:IC:;T~R n~ WII I c:; GLENDA FARNER STRASBAUGH REGISTER OF WILLS Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 10/30/2006 IRWIN HAROLD SIll 64 SOUTH PITT STREET CARLISLEr PA 17013 RE: Estate of BOLLINGER JOHN A File Number: 2004-01051 Dear Sir/Madam: This notice is to serve as a reminder that the Status Report by Personal Representative under Rule 6.12 is due on the below listed date. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULESr NO. 103 SUPREME COURT RULES DOCKET NO. lr for decedents dying on or after July 1r 1992r the personal representative or his counselr within two (2) years of the decedent's deathr shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing is due by: 11/05/2006 Please feel free to contact this office with any questions you may have. If you have already filed your Status Reportr please disregard this notice. SincerelYr # ,. a t/, . . l,p .. If, " / ffi~~ L~l1/w-'J.j~d?~rv Glenda Farner Strasbau~h Cle~k of the Orphans' Court cc: File Personal Representative(s) \ ) Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 10/30/2006 KOHR ARLENE S 2466 MERCER STREET HARRISBURG, PA 17104 RE: Estate of BOLLINGER JOHN A File Number: 2004-01051 Dear Sir/Madam: This notice is to serve as a reminder that the Status Report by Personal Representative under Rule 6.12 is due on the below listed date. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with 1:he Register of Wills a Status Report of completed or uncompleted administration. This filing lS due by: 11/05/2006 Please feel free to contact this office with any questions you may have. If you have already filed your Status Report, please disregard this notice. Sincerely,_ , V~ ", /J 1/' ~' 'T' II ' "j '/r. ' , ~zu /1I!t~ Lt-;Wt/~' /' (~ Glenda Farner Strasbaugh Clerk of the Orphans' Court cc: File Counsel \ err Register of Wills of Cumberland County STATUS REPORT UNDER RULE 6.12 Name of Decedent: J'"0\\l\) L~LLt{\JtoE:f0 Date of Death: ~D~'dt~~ ~ \ 2.004 Estate No.: 2.\D4 - ID 5 1 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: I. State~h;;;oer administration of the estate is complete: Yes j){ No 0 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. Ifthe answer to No.1 is Yes, state the following: a. Did the person~resentative file a final account with the Court? Yes 0 No)2Sl 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? Y es ~ No 0 c. Copies of receipts, releases, joinders and approval of fomlal or infomlal accounts may be filed with the CI rk 0 the Orphans' Court and may be attached to this report. Date: 11- 3-oCo ~~ Address ~, :) ~\\\ ( ~~RL\$lE t eft }~013 (\\~ ') 2Jt3-fo(JC{O Telephone No. Name '1--" ;V f'f ~ I' ; "-J ~ (, . 1.~J L- ;, ....,..... ',' :. / ~, , ..'. '-' '...; ,..; Capacity: 0 Personal Representative ~ounsel for personal representative BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION PO BOX 280601 HARRISBURG PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEP~RTMENT OF REVENUE ,""==-:.('r. i ':. ',INHERITANCE TAX STATEMENT OF ACCOUNT '* i; \\: 25 REV-1607 EX AFP (03-05) HAROLD S IRWIN III IRWIN LAW OFFICE 64 S PITT ST CARLISLE PA 17013 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 07-10-2006 BOLLINGER 11-05-2004 21 04-1051 CUMBERLAND 101 JOHN A Allount Rellitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent. REV-1607 EX AFP (03-05) --------------------------------------------------------------------------- --+ RETAIN LOWER PORTION FOR YOUR RECORDS +- ~~~ INHERITANCE TAX STATEMENT OF ACCOUNT ... ESTATE OF BOLLINGER JOHN A FILE NO. 21 04-1051 ACN 101 DATE 07-10-2006 THIS STATEHENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAHED ESTATE. SHOWN BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYHENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 06-12-2006 PRINCIPAL TAX DUE: .00 PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 04-21-2006 CDo06588 .00 2,904.94 06-22-2006 REFUND .00 2,904.94- TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 II! IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .00 SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS. ) ~~V