HomeMy WebLinkAbout08-22-13 � 15056Q7121
REV-15Q0 � c�-�, OFfIGiALUSEONLY
PA�eperiment of Revenue Coun C
Bureau of ItMividual TaYes tp wle Y i r � file N�mber
P080X 2$0661 INHGRITANCE TAX RETURN r'� , � �1 q
Hamsbum,PA t7128-0601 f2ESIDENT DECEDENT a��
ENTER DECEDENTINFORMATiON BELOW
Socia4 SeCUrity Number Date of Death Date of Bi�th
0 9 2 1 2 0 1 1 0 6 2 2 1 9 9 0
pecedenPS Last Name Suffix DecedenPs First Name MI
B l 4 S E R B E N J A M I N P
{I#Appi7cable}Enter Surviving Spouse's IMormation 6elow
Spnuse's Last Name Suffix Spouse's First Name AAI
Spouse's Socia�Security Number
THIS RETURN MUST BE FI�ED IN DUPUCATE WITH THE
REGISTER OF WILLS
Fltl IN APPRttFR7A'PE OYAL$8E14W
Q 1. Original Retum � 2.Supplemental Retum � 3.Remainder Refurn(date of tleath
pnorto 12•13-827
� 4.Limited Estate � 4a.Future Interest Compromise{data of � 5.Federal Estate Tax Retum Required
death aRer 12-12-82)
I] 6.Decedent Died Testate � 7.Dacedent Maintained a Living Tmst i 8.ToYal Number of Safe Deposit Boxes
(Attach Copy of Wili} {Attach Copy af Truat)
� 9.litigation Proceeds Received � 10.Spousal Ppverty Credit(date of deatb � t t.Etec#ion to tax under Sec.9113{A}
between t2-31-91 and 1-1-95) (Attach Sch.O)
CORRESPONDENT-THIS SECTION tAUST BE COMPIETED.AL�CQRRESPOMDENCE ANO CONFIDENTIAt TAX INF�MItTHN#SMOtit�BE�ECifp T0;
Name paytime pgone Num6e� ��'i m
c'�
WI L L I AM DCYUGLAS 71 � '..�, 43�,-,1 �; �'Q
Firm Nama(If Appii�bie) ..---R�--���prmLL�E OM�,,�I
vr,rr�
DOEIGLAS t� AW QFFI CE I � � , : , .,
� Firsl Iine of eddreas � '�'' �` � ����i �
� G7 �o _
4 3 W . S O U T H S T . �, •° ;:, �•-� ����' ���� �
Second iine of addresa '� � � c.'? �-' `'"' ��
' � F� �� �
�
� DATE FILED (
GityorPOSt4ffice State ZIPCode �— .—._.... __. ___-_.. ._._
G A R L I S L E P A 1 7 Q 1 3
CorrespondanYS e-msil address:d0UpI85I8W(d�@81thlilik.fiG't
Umkr pena�ies of pe�Jury,i Gedare that t have e�mined Uds reexn,in�irg sccomparrya�scheduks ar�d s�teme�b,and to the best of my knowiedge and beAef, -
it is We,correcl and wmplate.Dedaration ot preparer other Ihan the personal representadve is based on all infortnaGOn o(wh(ch preparer hes any knowledge.
SIGNATURE OF PERSON RESPONSBtE POR PIIiNG RETURN DA7E
ADORESS
St NA RE PREPARER E THA REP SENTATIVE 6A
ADQRESS
PI.EASE USE dRIGINAL F6RM ONLY
Side 1
� 1505607121 1505607121 � 1
Q�y
J 1505607221
REV-1500 EX
DecedenPs Social Security Number
oecedenesName: BENJAMIN P. BLOSER
RECAPITULATION
1. Real estate(SChedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.
2. Stocksand Bonds(Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.
3. Closely Hald Corporation, Partnership or Sole-Propriatorship(Schedule C) . . . . . 3. .
4. Mortgages&Notes Receivable(Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . 4.
5. Cash, Bank Deposits&Miscellaneous Personal Property(Schedule E) g, 4 � 1 9 3 3 , 6 �
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested . . . . . . . 6. .
7. Inter-Vivos Trensfers&Miscellaneous N n-Probate Property
(SChedule G) � Separate Billing Requested . . . . . . . 7. ,
B.ToWIGrossAasets(totalLinesi-7) . . . . . . . . . . . . . . . . . . . . . . . . . . . g 4 O 1 9 3 3 , 6 0
9. Funeral Expenses&Administretive Costs(Schedule H) g. � 0 0 6 2 , 9 2
. . . . . . . . . . . . . . . .
10. Debts of Decedent, Mortgage Liabilities,8 Liens(Schedule I) , . . . . . . . . . . . 10.
11, ToWI Deductions(total Lines 9&10) . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. � 0 0 6 2 , 9 2
12. Net Value of Esfate(Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . 12. 3 9 � $ 7 � , 6 $
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not baen made(Schedule J) , , , , , , , , , , , , , , , , 13. ,
14. Net Value SubJect to Tax(Line 12 minus Line 13) . . .. . . . . . . . . . . . . . . 14. 3 9 � $ 7 � , 6 $
TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
trensfere under Sec.9116
(a)(12)X.0 _ 0 . � � 15. � . � 0
16. Amount of Line 14 taxable
at lineal rate x .000 3 9 1 8 7 0 . 6 8 �s. 0 . 0 0
17. Amount of Line 14 taxable
at sibling rate X.12 � , � � �7. � . 0 p
18. Amount of Line 14 taxable
at collateral rate X.15 � . � 0 18. � , p 0
19.Tax Due . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. � . 0 0
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT �
Side 2
� 1505607221 1505607221 J
REV�150tl E3� PBge 3 File Number
Decedent`s Complete Address: � o
DECEDENT'S MAME
BENJAMIN P. BLOSER
- - - -- __- - ---- ---- --- - .—.- --- -
STREETA6DRESS - .. --- .—...-- ----------.,—..
._—_._. .._._ —_.. _------`_.._--------------- ----..—.,—�---- -. ..—_------_.--- --- --._..—_ ._..__—..
CITY �STATE � �ZIP
Tax Payments and Credits:
t. Tar Due(Page 2 Line 19} (t} $O.dO
2. Credils/Payments
A.Sppusal Povedy Gredii
B.Prior Payments
C.Discaunt
Total Credits(A�B+C) (2) $Q.00
3. fnteresUPenaity if ap�icabie
D.Interest
E.Penalty
Total Interest/Penalty(p+E) (3) $0.00
4. if Line 2 is greater than�ine 1+u�y 3,enter the difference.This is the OYERPAYIAENT.
Fill In oval on Page 2,Line 20 tp request a refund. {4} $p.00
5. If Line 7 +Line 3 is greater then Line 2,enter the difference.This is the TAX DUE. (5? $Q.00
A.Enter the interest on the tax due. {5A)
B.Enter the total of Line 5+5A.This is ihe BALANCE DUE. {SB} $0.4Q
Make CheckPayab/e ta�REGlSTEROfW1ll5,AGFNT
� , . Ci ._ , � �.', � . �!;; . '� �s,t ,
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN"X" W THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use�incame af the properfy Gansferred� ...................................................................... ❑ Q
�. retain the right to designate who shall use ihe property trans(erted nr its iocome; ..................._....... ❑ Q
c, retain a reversionary interest�a ................................................................................................ ❑ �
d, receive ths promise for life of either payments,beneflts w care? ..........
.............................................
2. if death occurred afler December 12,1982,did decedent transfer property within one year of death
tvithouireceivirx��uateconsic�tation? ....................................................................................... ❑ 0
3. Did decedent own an"in trust for"or peyable upon tleath bank account or security at his or her death9 ......... ❑ (]
4. !?id decedent am an Individnal Ret+remeat Account,annuity,or other non-probate property which
contains a beneficiary designatlon?.................................................................................................. ❑ �
IF THE ANSWER TO ANY OF 7HE ABQYE QUESTIONS IS YES,YOU A�US7 GOMPIETE SCHEDULE G AND FII.E I7 AS PART OF THE RETURN,
«:: ;' � , , ��:`
For dates of death on or after Juiy 1,1994 and befare January 1,1995,the tax rate imposed an the net value of transfers to or ior ihe use ot the surviving spouse
Is three(3)percent(72 P.S.§9116{a)(1.1)(i)].
For dates of death on or after January 1,1995,the tax rate imposed pn the net velue of transfers ro or for the use of the surviving spouse is zero(U)percent
(72 P.S.§8116{a)(1.1)(li)j.The statute does not ex�nW a transfer ta a surviving sp�se from t�,�d fhe statutqry requirememts far disciosure#assets and
filing a tax retum are still applic2ble even if the surviving spousa is the only beneflciary.
For dates of death on or after J�ly i,2000:
The tax rate imposed on the net val�e of Vansters from a deceased chlld twenty-one yeazs of age or younger at death to or fa the use of a natur�parent,an
adop6ve parent,or a steppareni of the child is zero(0)percent[72 P,S.§9116(a)(1.2)j.
The t�rate impos�!on tfie net value of transfers to ar for the�se of the decedenPs iineal beneficiaries is four and one-half(4.5j percent,sxcepi as noied in
72 P.S.§9116{1.2)(72 P.S.§9116{a){t)).
The tax rate imposed on the net value of hensfers to or Cpr the use of the decedenPs siblings is twelve(12)percenl[72 P.S.§9116{a)(1.3)J.A sibling is d�ned,under
Sectlon 91d2,�an individual wtra has at least one par�t in Ganmon with the decedent,whether by bloaf or adoption.
KEV-15�8 Ek+(8-g8)
SCHEDULE E
GpF,�iONWEAI.TNOFPENNSYLVANiA �+AS(l, BANK DEPOSITS� 4t ���7�.
INHERITANCE TA7C RETURN PERSONAL FROPERTY
iiE5i6ENT DECEDENT
ESTATE OF FlLE NUMBER
BENJAMtN P. BLOSER o a
indude the pmceeds W CNgatiai and the date the roceeds were received by the esfate.
aa
All propeHy Jointlymwned wilh rlgh!ut survivon ip must 6e dkcbsad an Sthadub F.
ITEM VALUE AT DATE
NUMBER DESCRIP710N OF DEATH
1. 1st Choice Auto insurance Company Refund $207.33
2. 2011 Incame Tax Refund $1,326.d0
3. Pension from Fidelity Investments/Ahold#35845 $40�.27
4. Proceeds from Personai fnjury Settlemen#from First Choice tnsuranae 5250,Od0A0
5. Proceeds from Personal Injury 3e�lement from Natianwide $50,OOOAO
6. First Choice Underinsured Motorist Proceeds $100,000.00
70TAL.(Afso�ter on Eine 5,Recapitulation) S 401 $33.60
{!f rirore space�a needed,insert addifa�fsl st�1s of the sarre size}
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� � Pay to the Order of: � � . . . � .�
THE ESTA1'E 0 BEHJAMIN $LOSER Deutsche Bank Trust Company 6efaware
C�0 ST£VEN BLOSER ��2'"1""—
150 BARNS'fABLE ROAD
CARLISLE, PA 17�15
�.._`
. � � � uthorized Slgnature . �. �
n'0253778i54n' �:031i00380�: QD59Q3i1n'
THE OpIGlNAL DOCUM8N7 HAS A RE�LECflVE WAFERMARIS ON FtlE BAClC. HQID AT AN ANG6E T6 YIEW WtlEN CHECKtNtd TH@ fNDORBEMENT
_ _ .
��Fide/i A.
� N V E 5 T M E N T�
ENV#26620110324000266
BENJAMIN P BLOSER
150 BqRNSTABLE RD
CARLISLE PA 17015
03/24/2011
Re: Your Enrollment in AHOLD - HOURLY - 35845
Dear Benjamin P Bloser,
Con ratulations on becoming eli ible to participate in ihe Ahold USA, Inc.
401(�c) Retirement Savings Plan�Plan'). This Plan is a convenient way to
invest in your future by atlowing you to make pre-tax contributions (i.e.,
associate voluntary contributions) into a retirement account and receive
matching contributions from the Company.
Plan effeetive a�s of the Au omatie enlrolmen�date alnyd at the el�ect ons
noted below, untess you affirmatively decline to participate in the Plan
before your Automatic enroliment date. However, we encourage you to
take advantage of this great benefit and take an active role in your
retirement planning by reviewing the initial contribution amourd and
initial investment fund to ensure they meet your needs.
it you do not want to be automatically enrolled in the Plan effective as of
the Automatic enrollment date, you must edher:
Log on to NelB(enetits« at www.401k.com, and change your deduction
aCall the Aho d USA$I�nc.�401(k) Retirement Line at (800) 249-4015 and
ask to speak to a Fidelity Represerriative, 8:30 a.m. to 12:00 a.m. EST, and
tell the representative that you do not want to participate in the Plan.
If you prefer to enroll in the Plan before the Automatic enrollment date,
make chanpes to any of the elections set forth bebw or have any questions
about the Ptan's provisions, log on to www.qOtk.com or call (800)
249-4015.
Ahold USA, Inc.
Automatic enrollmenl date: 06/22/2011
Contribution source: ASSOCIATE VOLUNTARY
Initial contribution amount: Pre-Tax Basic 30�0
Initial investment mix: 2055 Retirement Fund
100%
Annual increase information:
Associate Voluntary �o�o
01/Ot/2073
Annual increase cap: go�o
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C�PEt tSY'lYr"�iN1t'�� � •�
Steven Bloser, individualIp;Steven In the Courk of Common Pleas af
Bloser, Administrakor aE the Estate of Cumberland Caunty, Pennsylvania
Benjamin P. Bloser, deceased; and
Steven Blaser Trustee Ad Litem on
behalf of aIl individuals entiUed to
share in khe praceeds for khe wrongful
death of Benjamin P. Bloser, deceased
Plainh'ffiPetitinner 2021 Civil Term 9039
vs
Civil Action—Law
lst Choice Auto Insurance Company Petition for Approval of Partial
Settlement and Distribution
Defendant/Res�ondent Honorable Thomas A. Ptacey
Petition for Aovroval of Payrnent af Liability Insnrance Proceeds
Excess Insuranee Proceeds and Partial Underinsared Matarist
Benefits and llistribt�tion
l. The petitioner, Steven Blaser, Individaallq and as Administrator of #he
Estate of Benjamin P. Bloser, deceased and Trustee Ad Litem for aU
individuaTs entitIed to share in the proceeds for the wrongful death of
Benj�nin P. Bloser, deceased, is an adult individuai currently residing at
150 Barnstable Road, West Pennsboro Township, Cumberland Counfy,
Pennsylvania.
2. The respondent, 1st Choice Auta insurance Company, a subsiiiiary of
ECM {Everett Cash Mutua2} is a business entity licensed ta and daing
business in tiie CammonweaIth oE Pennsplvania, with a place af business
located at 10592 Lincoln Highway, Everett, Pennsybaztia, I5537. Said
respondent is hereuta#ter referred to as'i�Choice'.
3. On or about September 21s`, 2021, at apgroximately 6:40 arn the decedent,
Benjamin P. Bloser, age 21, was a passenger in a vehicIe being operated by
Natasha Haulman and awned by Martina Bloser.
4. Haulman operated the veh9cle in negiigent manner and as a direct and
proximate result of said negligence, HauIman lost control af the veh:icle
and struck a tree, causing both herself and Benjamin P. Bloser to be ki3led.
5. At the time of his death Benjamin P. Bloser was 21 years of age, single and
had never been married nor had children, He resided with his parents,
Steven and Martina Blnser in West Pennsboro Township, Cumberland
County, at 15Q 8arnstable Raad.
b. $enjamin P. Bloser's, intestate heirs are his mother Martina Blaser and his
father Steven $toser. He is also survived by a bmther Adazn Bloser who
also resided in the aforesaid household. His father was appointed
Admiruistrator of his Estate by the Register of Will of Cumberland County,
Pennsylvania at docket 21 -2011 -Q1219.
7. The vehide that was being aperated by Natasha Haulman was owned by
Martina Bloser and insured by Benjamin P. Blaser throixgh 1st Choice
Auto Insurance Company.
&. The policy of insurance Benjaznin P. $loser maintained with ist Cho3ce
Auto Insuranee Caznpany (policy numBer PAP204t101} extended liability
caverage, to the permissive drivers of car he was oecupying, in the
aznounY af $25Q,40Q.44. 1" Choice has now tendered their $250,000.00
liability policy limit.
9. Natasha Haulman was a rtamed drive in a policy of insurance issued by
Nationwide Mutua! Automobi2e Insurance Company that provides excess
liability coverage in the aznaunt af $5d,000.00 and NaSonwide has now
tendered their policy limit of$5QQ00.04 in excess liability coverage.
24. In addition, la` Choice Auta Insurance had issued underinsured matorisk
policies ta Steven and Martina Bloser (policy number PAP2Q2141) and to
Adam Bloser {policy number PAP202143). i&` Choice Anto Insurance has
tendered $100,000.00 in underinsured matarist caverage which represents
the amount af underinsured motorist coverage lgt Choice and the
petitioner agree is uncontested. 1�' Choice and the petitioner are
continuing to litigate the amount of additianal underinsured matarist
coverage that may ar rnay not be available.
i
11. There are no minor heirs involved in this matter and Benjamin P. Bloser
was under age 22 at the time of his death. The proceeds discussed herein
are not subject to Pennsylvania lnheritance Tax. All surns set forth above
consiitute darnages on account of personal injurylwrongful death, arising
Erom khe qccurrence, within the meaning of § 1{�{a}{2} of the Internal
Revenue Code o£148b, as amended.
12. Steven Bloser entered into a one-third contrngent fee agreernent with
Douglas Law t�ffice.
13. The petitioner respectfully requests that the settlement af the iiability
claims in the amount af $304,Op0.00 and the partiai settIement of the
underinsured motorist claim in the amount of$100,000.00 be approved.
14. The petitioner respectfiilly requests that payment of the aforesaid
pmceeds be paid to Steven Bloser, Administratar of the Estate of Benjamin
P. Bloser, deceased, and the distributian of the praceeds be approved,
15. ist Choice Auto tnsurance Comgany and Nafionwide Insurance Company
both canrur in the request to approve the settlement.
16. Distribution:
Steven Bloser, Adrninistrator $266,bb6.67
af the Estate of$enjamin P.Bloser, deceased
WilIiam P. Douglas $133,333.33
Douglas Law C?ffice
Total: $40�,0OO.Ot1
�
�
WHEREFURE, your Peti6oner preys that the payment of liability and under
insurance proceeds and distribution be approved in aemrdance with the
aforesaid.
W�,
Douglas, sq.
Douglas Law 'ce
43 W. South t.
CarlisIe, Pennsylvania
TeI (717} 243-1740
Fax 717) 243-8455
dougtnslaw@enrthtink.net
February 12, 2013 Attorney far petitioner
Steven Blaser, individualiy;5teven Tn the Court af Common Pteas of
Blaser, Administrator of the Eskate of Cumberland County, Pennsylvania
Benjamin P. Blaser, deceased; and
Steven Bloser Trustee Ad Litem an
behalf of all individuals entitted to
share in the groeeeds for the wrongfiil
death of Benjarnin P. $loser, deceased
PlaittYiffiPetitioner 2011 Civil Term 4039
vs
Civil Action—Law
ist Chaice Auto Insurance Company Petitian for Approval of Parti�l
Setttement and Disiribution
DefendantJRespondent Honorabie Thomas A. Ptacey
I AFFIDAVIT '
I hereby swear or affirm tltat the Faregoing is t�ue and carrect to the best of my
knowiedge andl ar informatian and belief.
This is made subject ta the penaIties of 18 Pa.C.S. §4904 relating to unsworn
falsificaCion to authorities.
,
Wi iam P. rnag
for Steven Bloser
February 12, 2013
Steven Bloser, individuallp;Steven In the Caurt of Cammon Pleas of
Bioser, Administratar of the Es#ate of Cumberland County, PennsyIvania
B�njamin P.Biasez�, deceased; and
Steven Bloser Trustee Ad Litem on
behaif of all individuats entitled to ;, „� �
share in the proceeds far the wrongfut G ° '`
death of Benjaznin P.Bioser, deceased rn� � �-�
z� � �r
PtaintiffiPetitioner !r- qa.�9 �� � Q�
(�'� MC;
A� � t�'3-�r..
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lst Choice Auto Insurance Company Praeape to withdraw Petitior�#or
Approvat dated 02.12.2013
Defendan t/Resportden t
Prae+cipe to Wi4hdraw Petition dated February 12 2013
i
Piease withdraw the Petition filed in this matter dated February I2, 2013 as it
was filed to the wrong term and number. Par reference convenience the canect
term and number of the above named actian is 20i i Civii Teim 9d39.
�
������
William P. Dougi
Counsel for PlainiiffiPeti er
February 14, 2413
, • �
Steven B2aser, individuallp;Steven In the Court of Common I'teas o#
Bloser, Administrator of the Estate of Cumberland County, Pennsylva�ia M,
Benjamin P.Blaser, deceased; and �.'
Steven Btoser Trustee Ad Litern on �j `"' '�" -
�v: -+� r,...
behalf af atl individuals enfitled to x`,; � - •'�"
share in the proceeds for the wronghil ��r N ,'3:y;'
death of 8enjamin P.Btaser, deceased ;=:: T
ic. ��, _
- w:
Plaintiff/Petitioner 2011 Civil Texae 9039 �"�l' �
` f_1 .
nl
VS
Civil Action— Law
Ist Choice Auto Insurance Campany Petition#or Agproval of Partial
Settiement and Distribution
Defendant/Respondent Hanorable Thomas A. Plaeey
ORDER
AND NOW, on this the�ti�day of February, 2p13, }he settlernent of the liability
claim is approved. The payment of$250,04Q.4Q in liability insixrance proceeds by
1st Choice Auto insurance Cornpany and $50,000.06 in excess liability insurance
proceeds by Natianwide Mutual Insurance Company ta the Estate of Benjamin P.
Blaser is appraved. The payment of underinsured motarist proceeds ta the Estate
of $enjamin P. Bloser, in the amount of $100,000.OQ and the distribution as
requested in the attached petitian is approved,
By the Court,
!"'"'—"""
J,
Thoma . Piacey
Comman P�eas ludge
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REV-1571 EX+(70-98)
SGHEDULE H
COMMONWEAITH K}F PENNSYLVANIA FUMERAL EXPENSES 8
INHERITANCE TAX RETURN ADMINtSTRATlVE COSTS
REStDENT DECEDENT
ESTATEBF FRENUMBER
BENJAMIN P. BLOSER 0 0
Deb4a ot decedent must bs reported an Sehedale l.
}7EM
NUMBER DESCRlP710N AMOUNT
A. FUNERALEXPENSES:
1. HOFFMAN ROTH FUNERAL HOME $9,642.54
reimburse steve for cemetery how much? did anybody pay anything on fh bill
B. ADMINlSTRATIVE COSTS:
1. Personai Represeniative's Commissions
Name oP Personal Representative ls�
Sheet Address
Ciry Sate Zip
Yea�(s)CommissWn Paid:
2, Akomey fees
3, Fam�y Exemptian:(N decederKs address is not the sama as daimanPs,atfach expiznatbn)
Ctaimant
Sireet Address
City State Zip
Relationship at Claitta�nt to Decedent
4. ProbateFees L.ETTERS $68.5q
5 AcxouMenCSFees
6, T�Retum Preparers Fees
7. SENTiNEt� $263.88
8. CUMBERl.AND G4W JC}URNAL $75.Od
9. DEB PIPER-Tax Gallector $11.00
1�. BIG SPRWG HIGH SCHOOL-recards request $2A0
TOTAL(Also eMer on iine 9,Recapftulffiion) S 10 082.92
(If more space is needed,insert addHbnal sheets of Ne same size)
219 North HanoverStree�t
Cadisie,Per'insylvonia 17�13
717243.457 1
r ;' ! 3
,.�f r J� ,{/ toll hee 1.866.451.451 1
t':. . : i.r..: ,� �1� ��t'� �x�� �� �:- F.''�I ` �� fax 717243.3723
-- ` w�wv.Faffrrnrrom.can
FUNERAL HOME �ST CREM1�TtJRY, IItiIC. inroc+�otnnarrom.car�
October A, 2011
Steven 9loser
150 Bamstable Road
Cariisle, PA 17p15
5tafement of Funerai Expenses for: Benjamin Pash Bloser
Date of Death: September 21, 2011 Accqunt Id: 16343-208
PACKAfi�E:
Traditional Eunera!Service
TRADITIONAL FUNERAL SERVICE PACKAGE $ 4,650A4
Sub TotaL• $ 4,65QA0
MfRCHANDiSE:
Casket: 0ekiand 3 3,150.00
Outer Container. Gave Proof Box $ 1,1�5.Od
Sub ToWi: $ 4,325.40
TOTAL FitNERAL HOMf GHARGES: S 8,975.00
CASH ADVANCES:
6 Gertified Dea#h Certificates at$6A0 eaoh $ 36.Q0
Newspaper Natice-Senti�ei $ 180.14
Additional nCs $ 24.00
Newspaper Natioe- Public Opinion $ 135.pQ
Ftowers $ 42.40
Ciergy $ 100.00
Se�o� $ 50.00
drgenist $ 100.04
Sub Total: $ 66T.54
Totaf Fuosrei Expense: S 9,6+t2.54
Balance: S 9.642.54 i
--------------------------------------------------------------------------------_
Please return this portiort with your Remittance.
$ Amount Enclosed
Benjamin Pash Bioser
Seroice!U#: 16343-206
$ E R V I N G O U R C O M M U N i T Y S I N C E 1 9 O 7
RECEIPT FOR PAYMENT
GLENDA FARNER STRASBAUGH Receipt Date : 11/14/2011
Cumberland County - Register Of Wills Receipt Time : 14 : 09 : 12
One Courthouse Square Receipt No. : 1067703
Carlisle, PA 17613
BLOSER BENJAMIN P
Estate File No . : 2011-01219 - - -
Paid By Remarks : DOUGLAS LAW OFFICE
CJ
- - - - - - - - - - - - -- -- - - - - -- Receipt Distribution - - -- - - - - _ ____ _ _ _ _ _ _ _ _ _ _ _
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS ADM 20 . 00 CUMBERLAND COUNTY GENERAL FUN
SHORT CERTIFICATE 20 . 00 CUMBERLAND COUNTY GENERAL FUN
JCS FEE 23 . 50 BUREAU OF RECEIPTS & CNTR M.D
AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN
Check# 1577 --"--
Total Received. . . . . . . . . �68 . 50
�7..J �Qi�uiiPil t+v�va.na utrv v�rwc .A' �,. � ,�,
�w.cum6arltnk.com 43W.SOUTHST. �404996 10f7v
�1 )�,/^�� CARLISLE, PA 77p13 BILL DATE ^ SAI.�SPERSON
�OG'VG� 4 T17-243-178Q
''y�—� 12J25111 waFfc
��� ;��.�ue� ��sxw�cv�rirr
START DATE S7QP DATE
12/10l71 12l24l11 �
AD NUMBER AD DESCRIPTION CLASS LINES
404998 ADMINI$TRATOR'S NOTICE LETTERS OF 10 PUBLIC NO7ICES 48 * 2 cols
Publicatlon Insertlons Rate Net Amaunt Grass Amount
3 THE SENTINEL-LEGAL 3 - LGL $254.88 �
TOTAL AD CHARGE $Zr�q�g
3 PROOF OF PUBLICATION 01 PRF $7.Op
3 MOBILE SITE MOB2 $2,p0
purcbaae order Est. B. Bloser PAY THIS AMOUNT $263.88 $316.66'
'AF7ER 01H9112
, THE SENTINEL
Thank you far adverti&ing with The Sentir�sl! Dsadtine for cla LEE NEWSPAPERS
in-column iegai ads is 4:00 p.m. two business days prior to PO BOX 540
date of insertion. For questions, call (717)240-7130. WATERLOO IA 50704-0540
R�wm ehp pallon wffh your p.ymonf Legel
THE SSN7INEL ❑ Check# �CredR Card Ad Number '��Q9�
C/o LEE NEWSPAPERS � � ❑ � ❑ � ❑ - g�lling Date 12125N1
PQ BOX 540
WATERl00 IA 50704-0540 �#: Amount Due $ 263.$8
Exp.Date:m m
Name an credit caM $ . �
Slgnature
Pleeae make checks payable ro: THE 3ENTINEL . .
000-za�
THE SfNTINEL
DOUGLAS LAW OFFICE c/o I.EE NEWSPAPERS K~"`
43 W. SOUTH 3T. p0 BOX T42'346
GARtiSLE,PA 17Q13 GINC�NNATI OH d3?7M2548
Ll�d�id���LIL�dJ��l��l�i�t,l��l��ll„L�I��II��Lf���ll
2154�20�O�afl04�49960Cii]��ODOCI�DOtI0D31666DEtOC10263889
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CUMBERLAND LAW JOURNAL
32 SOUTH BEnFORO STREET
CARLIS�E, PA 17013
Te�e: (717)249-3166 Fax:(717)249-2663
January 6, 2012
Cumberland Law Journal is published every Friday by the Cumberland Cou�ty
Bar Association and is designa#ed by the Caurt a#Common Pleas as the a�cial legxl
publication for Cumberland County and the legal newspaper for pub(ication of fegal
notices.
TC1: �l(iam P. Dauglas, Esquire
RE: Benjemin P. Blaser Estate
Legal adverkisements musi be received by Friday Noan. All legal advertising
must be paid in advance. Make all checks payable to: Cumberland Law Journal.
Advertisement inserted on the following dates:
December 23, December 30, 2011, and January 6, 2012
Advet#ising Cost $ 75.00
Proaf of Publicatior� $ 0.04
5econd Proof Request $ 0.00
Payment received $ 0 .00
Totat Atnount Due $ 75,00
Payment received by
DOLIGLAS LAW OFFICE
�s �v, s�„ri� s�
CARLISLE,PENNSYLVANIA 17013-0?G2
WILLIAMP. DOUCL9S, ESQ.
717-243-/790
FfLY: %17-2�3-8955
EMAIL:do:�sluslrzze;(F,rie¢o�thlivxk.raet
CEP.TI Fl ED AS A OPIC TRIAL ADVOCATE BY
THE NAT(ONAL BOARD OF TR IAL,9DVOCAC i'
January 13, 2012
Deborah W. Piper
Tax Collector
PO Box 157
Plainfield, PA 17081
Re: Benjamin P. Bloser
Date of Death: 09/21/11
Dear Ms. Piper:
I represent The Estate of Ben Bloser who passed away in Septeinber.
I have enclosed a check in the amount of$11.00 for Ben Bloser's 2011
Personal Taxes. We were concerned that additional taxes are due since it is past
the December deadline. We tried to reach you by phone but were unable as the
mailbox was full. We have gone ahead and mailed the $11.00 check but request
that you let us know if any additional taxes are due.
Should you have any questions, please feel free to contact me.
,,. .._ � _ �—
2077 Statement of Personal Taxes Conhol�No 046 008545
DEBORAH W.pIPER,TAX COLLECTOR Bill Date: 7/p7/pp��
P O BOX 157 BIG SPRING SCHOOL DISTHICT
TEM ORARY ETURN SERVICE REQUESTED Rate/C , �Diacount Face
5.00000 Penalt
SCH P Z yE
10$
Rate 5.00000 4'90 5.00 5.50
SCH RES 2� 1 O$
4.90 5.00
TAX AMOUNT DUE-----> s.so
$9.80 $10.00 $11.00
=f peid On or Af[er
If Paid On oi HefoiC ��01/2011 9/O1/2011 11/O1/2011
B 31/2011 10 31/2011 12/31 2011
50 BARNS ABLEIROAD CASH pg MONEY ORDER AFTER 12/Zq/11. RETURN BOTH COPIES OF
CARLISLE Pq 77p�5 BILL ANp ppSTAGE PAID ENVELOPE IF YOU REQUIRE A RECEIPT.
TUESDAYANDTHURSDAYBAM-4PM
AT WPT BLDG 2150 NEWVILLE RD
DEC,JAN,FEBBYAPT pH(777)440-
6680 FqX(777)2q3_g2gg Taz Collector Signature Dat Pe aid $ Amount Paid Enclose Self Addressed Stamped Envelope
Return Bill with Payment. For a Receipt,
REV-t5t3 EX+(9-p�}
SCHEDULEJ
C4MM6NWEAI.TH OF PEFlNSYlVAP7IA SENEFtC1AR1ES
INHERITANCE TAX RETURN
RESIDEN7 DECEDENT
ESTATE OF PILE NUMBER
BENJAMIN P. B�dSER {} 0
RELATIONSHIP Tp DECEDEN7 AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not Liat Truatee{s) OF ESTATE
I TAXAB(.E DlSTRIBUTIQNS {inGuds autrght spousai tl'usl�6utlons,�nd transf�s u�er
Set.91S8 a} L2)j
1, Steven Bloser Line81 $195,935.34
15Q Bernstabie Rd
Carlisle, PA 1�015
2. Markine Bioser Lineai $195,935.34
150 Barnstable Rd
Cariise, PA 17013
fNTER DOlL4R AMOUNTS FOR DESTRIBUTIONB SNOWN A64VE ON LINES 16 THR4UGH 18,AS APPR4PRIATE,ON REV-150d COVER SNEET
II. NON-TAXABLE DISTRIBUTIONS:
A.SPOUSAL DISTRIBUTIONS UNDER SEC710N 9119 FOR WHICH AN ELECTIQN TO TAX IS NOT BEING MADE
4.
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART lI-ENTER TOTAL NpN-TAXABLE DISTRIBUTIpNS ON LINE 13 OF REV•1500 COVER SHEET E
(If more space is needed,insert additional sheets of the same size)