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HomeMy WebLinkAbout10-14-13 Pennsylvania 1505610143 J OEPLRTMEW OF RREMIE EX(06-13) REV-1500 OFFICIAL USE ONLY County Code Year File Number Bureau of Individual Taxes PO BOx.280601 INHERITANCE TAX RETURN 21 13 0085 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 01 13 2013 01 31 1934 Decedent's Last Name Suffix Decedent's First Name MI ROMBERGER HANS S (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 1. Original Return 2. Supplemental Return 3. Remainder Return(Date of Death Prior to 12-13-82) 4. Limited Estate 4a. Future Interest Compromise 5. Federal Estate Tax Return Required (date of death after 12-12-82) 8 Decadent Died Testate 7 Detcaedenopy of fined a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) G 9. Litigation Proceeds Received 1o.Spousal Power J%refit{Dat9i f Death 11.Election to tax under Sec.9113(A) bet.en (Attach Schedule O) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number RONALD M KATZMAN ESQ 717 234 4161 First Line of Address 4250 CRUMS MILL ROAD Second Line of Address C M PO BOX 6991 n - cn City or Post Office State ZIP Code F-, r :• m � � HARRISBURG PA 17112 2, L:; �I " REGISTER bF WILL"SE - .06% C:T REGISTER OF WILLS USE ONLY -nn rY) � MMDDYYYY � " ('moo CD T7 Correspondent's e-mail address: rmk oldber katzman.com DATE FILED STAMP Under pen s f perjury,I declare th I have amined this return,including accompanying schedules and statements,and to the best of In knowledge and belief, it is[rue IT nd co lete Decl on of p parer other lha nal representative Is based on all information of which preparer has an knowledge. SIGN U O ERSO N FOR FI G RETURN DAT o ert A. Romber er II A DRESS 6109 Smithfield Street Harrisburg PA 17112 SIGNATURE OF PREPARER OTHETH N R PRESENTATIVE DATE Ronald M. Katzman Esq. ADDRESS T7 4250 Crums Mill Road Harrisburg PA Side 1 J 1505610143 1505610143 1505610243 REV-1500 EX Decedent's Social Security Number Decedent's Name Romberger, Hans S RECAPITULATION 1. Real Estate(Schedule A)....................................................:.................................. 1. 750 . 00 2. Stocks and Bonds(Schedule B)............................................................................. 2. 105 , 978 . 00 3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C)......... 3. 4. Mortgages&Notes Receivable(Schedule D)........................................................ 4. 5. Cash, Bank Deposits&Miscellaneous Personal Property(Schedule E)............... 5. 192 , 051 . 32 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6. 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) u Separate Billing Requested............ 7. 8, Total Gross Assets (total Lines 1 through 7)........................................................ 8. 298 ,779 . 32 9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 30 , 784 . 57 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............................ 10. 12 ,590 . 59 11. Total Deductions(total Lines 9 and 10)................................................................ 11. 43 , 375 . 16 12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. 255 , 404 . 16 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J)............................................... 13. 14. Net Value Subject to Tax(Line 12 minus Line 13)............................................... 14. 255 , 404 . 16 TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 15 - 0 . 00 (a)(1.2)X.00 16. Amount of Line 14 taxable 0 . 00 16. 0 . 00 at lineal rate X .045 17. Amount of Line 14 taxable 0 . 00 17. 0 . 00 at sibling rate X.12 18. Amount of Line 14 taxable 255 , 404 . 16 ta. 38 , 310 . 62 at collateral rate X.15 19. TAX DUE................................................................................................................ 19. 38 ,310 . 62 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. El Side 2 L 1505610243 1505610243 J REV-1500 EX Page 3 File Number 21-13-0085 Decedent's Complete Address: DECEDENT'S NAME Romberger, Hans S STREETADDRESS 5225 Wilson Lane #3139 CITY STATE ZIP Mechanicsburg PA 17055 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 38,310.62 2. Credits/Payments A. Prior Payments 35,000.00 B. Discount 1,842.11 Total Credits(A +B) (2) 36,842.11 3. Interest (3) 4, If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4) Check box on Page 2,Line 20 to request a refund 5. If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5) 1,468.51 Make Check Payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred;............................................................................... ❑ ❑x b. retain the right to designate who shall use the property transferred or its income;.................................. ❑x c. retain a reversionary interest; or............................................................................................................... F d. receive the promise for life of either payments,benefits or care?............................................................ ❑x 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration?..........................................................................-........................................ ❑ 3. Did decedent own an"in trust for' or payable upon death bank account or security at his or her death?....... ❑ 4. Did decedent own an individual retirement account, annuity,or other non-probate property which contains a beneficiary designation?........ ......................................................................................................... ❑ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. �fk For dates of death on or after July 1, 1994 and before Jan.1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent[72 P.S.§9116(a)(1.1)(i)]. For dates of death on or after January 1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S.§9116(a)(1.1)(ii)). The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and fling a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an adoptive parent,or a stepparent of the child is 0 percent 172 P.S.§9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S.§9116(a)(1.3)1. A sibling is defined, under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. Rev-1502 EX-(0140) SCHEDULE A pennsylvania REAL ESTATE DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Romberger, Hans S 21-13-0085 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 compel led to buy or sell,both having reasonable knowledge of the relevant facts. Real property that Is jolntlyowned with night of survivorship must be disclosed on schedule F. Attach a copy of the settlement sheet if the property has been sold Include a copy of the deed showing decedent's Interest if owned as tenant in common. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Great Vacations Resort of Hershey, PA-One week, Bi-annual timeshare originally owned by 750.00 decedent and decedents sister,Jean Romberger,as tenants in common. Jean Romberger died on 04/15/2009, leaving all property to current decedent. Therefore, real estate timeshare owned solely by decedent on his date of death. Fair market value determined by comparable sales price, i.e., $1,500 for annual frequency as depicted on attached listings compares to $750.00 value for a bi-annual frequency. TOTAL(Also enter on Line 1, Recapitulation) 750.00 (If more space is needed,additional pages of the same size) Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule A(Rev.01-10) Rev-1503 Ex+(6-98) SCHEDULE B STOCKS & BONDS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Romberger, Hans S 21-13-0085 All property jointly-owned with night of survivorship must be disclosed on Schedule F. ITEM CUSIP VALUE AT DATE NUMBER NUMBER DESCRIPTION UNIT VALUE OF DEATH 1 024071102 506.862 shares of American Balanced Fund Inc-Com 20.8800028 10,583.28 2 1404OH105 100 shares of Capital One Financial Corp-Com 62.1025 6,210.25 3 166764100 291.8758 shares of Chevrontexaco Corp-Com 111.7940919 32,629.99 4 191216100 100 shares of Coca Cola Co-Com 36.8425 3,684.25 5 126408103 200 shares of CSX Corp-Com 20.548 4,109.60 6 31428X106 100 shares of Fedex Corp -Com 97.71 9,771.00 7 55261F104 5 shares of M&T Bank Corp-Com 1035.16 5.175.80 8 718172109 100 shares of Philip Morris Intl, Inc. -Com 89.1975 8,919.75 9 28.81781 shares of PNC Financial Services Group, Inc.- 199.9999306 5,763.56 Com 10 860630102 25.4063 shares of Stifel Financial Corp-Com 300 7,621.89 11 50 shares of Visa, Inc. -com 160.5276 8,026.38 12 949746101 100 shares of Wells Fargo&Co New-Com 34.8225 3,482.25 TOTAL(Also enter on Line 2, Recapitulation) 105,978.00 (If more space is needed,additional pages of the same size) Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B(Rev.6-98) Rev-1508 EX*(11-10) SCHEDULE E pennsylvania CASH, BANK DEPOSITS, & MISC. DEPARTMENT OF REVENUE INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Romberger, Hans S 21-13-0085 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Cash-Found in Decedent's apartment. 371.00 2 Stifel Nicolaus Acct#5986-2695-1A 29,586.53 3 2006 Buick Lucerne 11,550.00 4 Bookcase and Ajustamatic Bed 1,075.00 5 Lift Chair 110.00 6 Maroon Lift Chair 150.00 7 Miscellaneous household items 1.276.50 8 Asbury Communities, Inc. (Bethany Village),-Reimbursement of payment for garage space 15,000.00 paid by Decedent. 9 Comcast-reimbursement 5.24 10 Stifel Nicolaus Acct#6698-6844-1A-Beneficiary IRA 66,626.04 11 Thrivent Annuity 64,696.18 12 U.S.Office of Personal Management Returement Programs-Lump sum death benefit paid to 1,604.83 Estate TOTAL(Also enter on Line 5, Recapitulation) 192,051.32 (If more space is needed,additional pages of the same size) Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule E(Rev. 11-10) REV-1511 EX-(10.09) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX TURN RESIDENT DECEDENT ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Romberger, Hans S 21-13-0085 Decedent's debts must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER A. FUNERAL EXPENSES: See continuation schedule(s) attached 4,513.19 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions . Name of Personal Representative(s) Robert A. Romberger II Street Address 6109 Smithfield Street City Harrisburg State PA zio 17112 Year(s)Commission Paid 12,000.00 2. Attornev's Fees Goldberg Katzman, P.C. 11,000.00 3, Family Exemption: (If decedent's address is not the same as claimant's,attach explanation) Claimant Street Address City State Zio Relationshio of Claimant to Decedent 4. Probate Fees 408.50 5. Accountant's Fees 320.00 6. Tax Return Preparer's Fees 7. Other Administrative Costs 2,542.88 See continuation schedule(s) attached TOTAL(Also enter on line 9, Recapitulation) 30,784.57 Copyright(c)2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev. 10-09) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Romberger, Hans S 21-13-0085 ITEM NUMBER DESCRIPTION AMOUNT Funeral Expenses 1 Funeral Expenses-Including: Picture display, Pastor, Organist, Sexton, Sound system 679.19 engineer,and food after service. Expenses advanced by Executor, repaid by Estate. 2 Myers Harner Funeral Home-Funeral Expense. 3,834.00 H-A 4,513.19 Other Administrative Costs 3 Bill Hobble-Appraisal of furniture, items,etc. in decedent's apartment. 150.00 4 Cindy Fenton Appraisals-Fee to appraise household miscellaneous items. 250.00 5 Cumberland County Legal Journal -Publication Fees 75.00 6 Jeff Treaster-Payment for assistance in moving decedent's property from Apartment. 300.00 7 Mike Kreiser-Payment for assistance in moving decedent's property from Apartment. 500.00 8 Moving Expenses-Including:Truck rental,fuel, storage rental,and meals for movers 216.80 advanced by Executor, repaid by Estate. 9 Patriot News Co. -Publication Fees 232.02 10 Register of Wills, agent-Additional short certificates 10.00 11 Robert A. Romberger, II -Reimbursement of additional moving expenses advanced by 358.85 Executor, repaid by Estate. 12 Storage Depot-April &May storage. 291.48 13 Storage Depot-June&July storage(final bill) 150.74 Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.6-98) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Romberger, Hans S 21-13-0085 ITEM NUMBER DESCRIPTION AMOUNT 14 USPS-Certified mail fee. 7.99 H-137 2,542.88 Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.6-98) Rev-0512 EX+(12-08) SCHEDULE 1 pennsylvania DEBTS OF DECEDENT, DEPARTMENT TAX REVENUE RETURN INHERITANCE TAX RET MORTGAGE LIABILITIES AND LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Romberger, Hans S 21-13-0085 Report debts incurred by the decedent prior to death that remained unpaid at the date of death,Including unreimbursed medical expanses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Bank of America -Payment of claim in full against Estate 7,100.00 2 Bethany Village-Rent owed by decedent 2,436.28 3 Bethany Village-Rent owed by decedent 2,436.28 4 CCRX Bethany Village-Owed for decedent's prescriptions. 20.58 5 Chase -Decedent's credit card balance. 303.71 6 Home Instead -December home care provided to decedent. 241.74 7 PA Department of Revenue-decedent's 2012 Income tax return. 52.00 TOTAL(Also enter on Line 10, Recapitulation) 12,590.59 (If more space is needed,additional pages of the same size) Copyright(c)2008 form software only The Lackner Group, Inc. Form PA-1500 Schedule I(Rev. 12-08) REV-1513 EX.(0110) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Romber ,er, Hans S 21-13-0085 RELATIONSHIP TO NUMBER NAME AND ADDRESS OF DECEDENT SHARE OF ESTATE AMOUNT OF ESTATE PERSON(S)RECEIVING PROPERTY (Words) ($$$) I• TAXABLE DISTRIBUTIONS [include outright spousal distributions,and transfers under Sec.9116(a)(1.2)] 1 Christi Bond Niece 5,959.42 127 Oakwood Avenue Elmira, NY 14903 2 Tim Bond Nephew 5,959.35 12846 Skiway Avenue Waynesboro, PA 17268 3 Sarah Dunn Niece 8,939.15 13 Black Friar Road Rosemont, PA 19010 4 Charles Edwards Nephew 17,878.29 2438 W.Anderson Lane C1 Austin, TX 78757 5 George Edwards Nephew 17,878.29 Four Seasons Decorations 139 Turtle Creek Blvd. Dallas,TX 75207 See continuation schedule attached Continuation 193,681.40 Total 250,295.90 Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet as appropriate. NON-TAXABLE DISTRIBUTIONS: II. A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule J(Rev.01-10) SCHEDULE J BENEFICIARIES (Part I,Taxable Distributions) ESTATE OF: Hans S Romberger 01/1312013 210-26-5558 Item Name and Address of Person(s) Share of Estate Amount of Estate Number Receiving Property Relationship (Words) ($$$) 6 Chris Furry Nephew 17,878.29 1366 John Adams Drive Lancaster, PA 17601 7 Diane Hutchinson Niece 17,878.29 P.O. Box 267 Riverside, PA 17868 8 Sally Krow Niece 17,878.29 6411 Hunters Run Road Harrisburg, PA 17111 9 Gretchen Makai Niece 8,939.15 210 Rutgers Avenue Swarthmore, PA 19081 10 Linda Reeder Niece 17,878.29 327 N.Sycamore Street Altoona, PA 16602 11 Barry Romberger Nephew 17,878.29 7999 SE Eagle Drive Hobe Sound, FL 33455 12 Douglas Romberger Nephew 17,878.29 11 Kenwood Avenue Carlisle, PA 17013 13 Robert A. Romberger II Nephew 17,878.29 6109 Smithfield Street Harrisburg, PA 17112 14 Susie Romberger Niece 17,878.29 45 Circle Drive Camp Hill, PA 17011 1 SCHEDULE J BENEFICIARIES (Part I, Taxable Distributions) ESTATE OF: Hans S Romberger 01/1312013 210-26-5558 Item Name and Address of Person(s) Share of Estate Amount of Estate Number Receiving Property Relationship (Words) ($$$) 15 Dani Touhy Niece 5,959.35 555094 Mono Amaranth Tine Amaranth,Ontario Canada L9WOT3 16 Alice Ann Weakland Niece 17,878.29 1150 Johnstown Road East Freedom, PA 16637 17 Ralph W.Wire Nephew 17,878.29 311 S.Arch Street Mechanicsburg, PA 17055 Total 193.681.40 2 C,cy O 't3 LAST WILL AND TESTAMENT m OF HUNS S. ROMBERGER ^ C. �l I, HANS S. ROMBERGER, of Bethany Village, Mechanicsburg, Cumberland County, Pennsylvania, being of sound and disposing mind, do hereby make, publish, and declare this to be my Last Will and Testament,hereby revoking and making null and void all prior Wills and Codicils made by me at any time heretofore. ITEM I. 1 direct that all my legally valid debts, funeral and administrative expenses, and-d7bts in-curred-orpayable-because-of my-death,-shall-be-paid by my Executor,-hereinafter-named, — from my residuary estate as soon after my death as practicable. ITEM II. 1 give and bequeath those items of tangible personal property that are identified in any separate writing,which is dated,makes specific reference to this Will,and is signed by me at the end thereof, to those persons designated in such separate writing who survive me. If any item of tangible personal property is identified in more than one separate writing, I direct that only the separate writing bearing the last date shall govern the disposition of such item. ITEM III. I give,devise and bequeath all of the rest,residue and remainder of my estate, of whatever nature and wherever situate., as follows: T Said residue shall be divided into as many equal shares as there are nieces and nephews of mine who survive me by thirty (30) days and nieces and nephews of mine who fail to survive me by thirty (30) days but who have issue that do survive me by thirty (30) days; one such share shall be distributed to each of the nieces and nephews who so survive me, and one such share shall be distributed to, or divided among, the issue of those nieces and nephews who fail to survive me by thirty (30) days. It is my intention to include the issue of deceased nieces and nephews who are not living at the time I have executed this Will. Said deceased nieces and nephews at the present time are Robert Hultman, Karen Bond and JoAnne Billups. ITEM IV. I appoint my nephew,ROBERT A. ROMBERGER, II, of Harrisburg, PA, to be Executor of this my Last Will and Testament. I direct that my said Executor shall not be required to enter bond or famish surety in any jurisdiction. ITEM V. I authorize my Executors to exercise the following powers in addition to those given by law,to be exercised in their sole discretion: A. To retain any or all assets, real,personal or mixed, without regard to any principle of diversification, risk or productivity. B. To invest in all forms of property without restriction to investments authorized for Pennsylvania fiduciaries or executors. C. To sell at public or private sale;to`exchange,mortgage or ease or- -- - —° -` any period of time, and to repair, alter or improve any real or personal property, and to give options for sales,exchanges,or leases,for such prices and upon such terms and conditions as they deem proper. 2 D. To compromise any claim or controversy. E. To make distribution hereunder in cash, in kind, or partly in cash and partly in kind. F. To make any distribution hereunder for the benefit of minor beneficiaries or others,who, in their opinion,are incapacitated through illness, age, or other cause, directly to the beneficiary thereof,to the natural or legal guardian or the person who has custody of such beneficiary, or to apply any such distribution directly to the benefit of such beneficiary. The receipt of such persons to whom payment is made or entrusted shall be a complete discharge of the fiduciary in respect thereof. G. In general, to exercise all powers in the management of any funds which any individual could exercise in the management of similar property owned in his own right upon such terms and conditions as to them may seem best, and to execute and deliver all instruments and to do all acts which they deem necessary or proper to carry out the purpose of this Will. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will and Testament, consisting of four(3)typewritten pages,this ay of Lc}v� ¢r , 2010. /)`z�V (9�yc� (SEAL) I�ANS S. ROMBERGE 3 We,the undersigned,hereby certify that the foregoing Will was signed, sealed,published and declared by the above-named Testator, HANS S. ROMBERGER, as and for his Last Will and Testament, in the presence of us, who at his request and in his presence and in the presence of each other,have hereunto set our hands and seals the day and year above written, and we certify that at the time of the execution thereof,the said Testator was of sound and disposing mind and memory. residing at am residing at COMMONWEALTH OF PENNSYLVANIA SS.: COUNTY OF DAUPHIN We, HANS S. ROMBERGER,the Testator, and and , the 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 purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testator, signed the Will as witness and that to the best of his/her knowledge the Testator was at that time eighteen years of age or older,of sound mind and under no constraint or undue influence. A4NS ERGS WITNESS WITNESS 4 Subscribed, sworn to and acknowledged before me by the Testator, HANS S. ROMBERGER, and subscribed and sworn to before me by and witnesses,this day of 2010. Notary Public (SEAL) 134892.2 5 Search for thousands of timeshare resort resale listings Page 1 of 4 7. PINNACLE O : e .� VACATIONS AMIRT RES&"SFECIALESR WORLDWIDE 239.489.1995 uluv4ivvna Orc�NJkmrlevd OM1t11YY[M Search Results Advanced Search I Vacation Weeks Calendar Page 1 of 1 aj ' i= All offers will be presented Sort by: Pfice 26 listings View Mao THE SUITES AT HERSHEY i.�REQUESpIN,y-F,�ARMP:i14NF3 HERSHEY $1500 : - View Profile Listing 113;ID: 39955 90 Points i Frequency Vacation Club _Week Unit 6000 I Annual Bluegreen Vacation Club _ _. 47 Comments: BLUEGREEN POINTS r X i http://www.pinnaclevacations,com/search-results-aspx?prevpage=index.aspx&location=HERSBE... 7/30/2013 WARRANI'YDEED . . (ALTERNATE YEAR) Gmt Vaotmm Resort ofHemhey,PA-LLC.,a Michimn lcrhd liebif wmpmq(wRmively"Gmtm%whwe xkhcu is 2)�ented > Pak Drive,Hmhcy, l ma 17033, or the auto of and aher good and vahubk coruhkra i m p,id to . Chador by - a a ary a aw u CGraus�GRANTED Is pnYNd a .uofo Garrme¢main ml pmpwy Gboulad of Daophie Couj.Pemrylvarda(de - -Prapny").and dean'ded u faliuwx Om(t)Tonedum tmeren(s)madmhg of ove adrvided om mm&,cd ad second(11112e4 undivided haerw(q U fee simple as toms in ammrm hr and to the Mt"drarihd Cnndnmidmn Para).tog AC,with a mrmspm�d ng uUlKhal tderea m me Common Fundshhgs which are appmmm to such Condominium Panel,s well s the rmnrhg(R cchadw fda eve"mt. riemLr yesr to naervc,me ad occupy m Aaal"d Ural whino Grem Vawmu Rant of Heyday,PA.,A Currdamhume(Oct "?nPar7 Oil mdusrc a�Pub to se and enjoy rite Umitei Gamma Eianrcm ad Comma, Fumed its looted within or odhearlw appvmwht m ash AdpW Ura:ad(iit)mn.cxc wivc right to ua and egoy,the Ceemon Ehurema of me Project• W Reir imerdol pmpoaa,do' the Vatntira Week a om(U a more SPIV Vaotton Rdodr Cnp to a maximum d seven(i) day,and oigbb)hit tit Dehgmtm S id W rid ie)ow s dull poperiy MK hen remvad in ac W&.with Ile providom of dm efreo- not Rhea and Reguimkna promnljyhted by the Cunt Vacdkr Rewm of Herohey,PA.Cnodomiuium Aaveciadan, Im.,aR purom a to the Dedualiah ufCSSrdmrdamm hr Groh Vaodme Rcmn of ifnaley PA,.A Cmhda nUut,duly remordd in dm Potful Ram of Dauphin burp.P nryMdc in O frld Raudr Book '1077.ar Pqe / m deruBa amended(tie'Dmlamloo). 00 PSCd Nm Vhastioa Week De' 0.4T ��e• Mai NU'4T. Snsoe "M1QEQ Said Property"I alao 4 aubjW to Rensaccaiq tie paymed of ad vd m tare fw 1le Anna.0 di mthmqumt yam.dl mrmdimn(including mineral reRrmb¢V.omamdig mhtccal royalties msUa fie Geemeea,wremhm,mtditom,and rntiohma of accord to me Public Ramda of D&%Aia Cenmy.Penmylmn's,and applahk m tla Property,Udall viar3le ad apparent aSmeds on t4 grwud. to parRodar,Be Property b mbJm m the Ocluation. TO HAVE AND 70 HOLD the Prop",togethe with all and da9ds,the rW"and appmmatusa thereto aed in arywiec Wongmg,urea A.said Grmee,m mcasmm ad axigs,lcan r ,sad Grow doe heaby bird)melf.in swomwars and aaism m Wsnm ad Fpmer Defend all sad singular the Plopcoy orm Oct sad Grdm by sacesws and aadgr,ap}lat away permn wheomeaeriawtbdy clamriog or to emlm the veer or any part memt ElflicU'1FD mDauphloCmdp,SWC OfPmroylvaoa,this _dayof '�WWSARyt .1998. Wham; n J I)Uc PrimedNmnc�'rX,f�✓)n .ae-L L PdnWName: 4 c. C, wen ' rid 71 ,,,94 ma — y Pr idi`6av�per/ inted New: n a.IS n taw m— rwn - PilddName/JJ.♦;"! eJ v�O.vti e [L PMnW Nanue�e� � (Cj yr�O m To Wimerm/b(X/YiAr/ /IIC.�oIFe�'a- � ._ Mood Name y /Yxb IlCM/ GrATEOFA— ) m COUNIV OFAJ) Th. foregoing Womanly Dad wu mimowkdged bdam trs Nis day M ANUAA. 19.x, by ALT®MS TbryaaperumllyWoomtomacar oed . /Yd TCe m s aidcvtilkdion utldkmleet:maM. Nalay PUbge,SmtoN a . • �✓Art��t`+•1 Cmvty, Pridedname (.Y:/InPwPH A J/% xxF Myeamedmembrs 9-17-x471 (NOPARIALSFAL) Irrational lx' /[q.T (/aLOXipgS �.sJ 1• Snp 4 ANae,Squire - a7w n�l.,� SGkd®srM Flat - �ijE /GALA e Sus lloaarHOalersN,RZOP,r.D.Aoa9pog ' � /Q' Sao / n HaWnd,Mhhlgis/si219u0H _� /lL�" l/a/2uldG /A /QOO e/ hWUntWSeat J Dom AL D'urr�+t.- Pnmk D' wf•ou^tY ury - .w). pj�r� O a(y(.'ornrrnSamn EaWaa Suph.t 2n.v D0108 Ira'F 001 Aaaehl m ll0!10-MI•n v te Historical Prices Date of Death: 01/13/2013 Account of: HANS S ROMBERGER Valuation Date: 01/13/2013 Account: 62681242 Processing Date: 09/27/2013 Number of Securities: 12 File ID: 62681242 Shares Security Mean and/or Div and Int Security or Par Description High/Ask Low/Bid Adjustments Accruals Value 1) 506.862 AMERICAN BALANCED FD (024071102) CL A Mutual Fund (as quoted by NASDAQ) 01/11/2013 20.88000 Mkt 20.880000 10,583.28 2) 200 CSX CORP (126408103) COM New York Stock Exchange 01/11/2013 20.67000 20.29200 H/L 01/14/2013 20.78000 20.45000 H/L 20.548000 4,109.60 3) 100 CAPITAL ONE FINE CORP (1404DH105) COM New York Stock Exchange 01/11/2013 62.79000 61.84000 H/L 01/14/2013 62.90000 60.88000 H/L 62.102500 6,210.25 4) 291.876 CHEVRON CORP NEW (166764100) COM New York Stock Exchange 01/11/2013 112.07600 110.80000 H/L 01/14/2013 112.95000 111.3500D H/L 111.194000 32,629.99 5) 100 COCA COLA CO (191216100) CON New York Stock Exchange 01/11/2013 36.94000 36.52000 H/L 01/14/2013 37.11000 36.80000 H/L 36.842500 3,684.25 6) 100 FEDEX CORP (31428X106) COM New York Stock Exchange 01/11/2013 97.78000 97.11000 H/L 01/14/2013 98.74000 97.21000 H/L 97.710000 9,771.00 7) 5 M. & T BE CORP (55261F708) ?ERR PFD-C New York Stock Exchange 01/11/2013 1035.00000 1035.00000 H/L 01/14/2013 1035.32000 1035.32000 H/L 1035.160000 5,175.80 8) 100 PHILIP MORRIS INTL INC (718172109) COM New York Stock Exchange 01/11/2013 89.83000 68.53000 H/L 01/14/2013 89.66000 88.77000 H/L 89.197500 8,919.75 9) 200 PNC FINL SVCS GROUP INC (693475857) DEPOSITARY SHS R New York Stock Exchange 01/11/2013 28.600D0 28.42D00 H/L 01/14/2013 28.47000 28.25000 H/L 28.435000 Div: 0.382810 Ex: 01/11/2013 Rec: 01/15/2013 Pay: 02/01/2013 + 0.382810 26.8176i0 5,763.56 10) 300 STIFEL FINE CORP (860630300) SR NT 22 New York Stock Exchange 01/11/2013 25.4063D Mkt 01/14/2013 25.40630 Mkt 25.406300 7,621.89 Page 1 This Report was prepared by Stifel Nicolaus, from information provided by its client, using the EstateVal system, a product of Estate Valuations & Pricing Systems, Inc. Stifel Nicolaus, its employees and financial advisors are not estate planners and cannot provide tax or legal advice. Please consult a qualified attorney or tax advisor regarding the information contained in this Report. Please review the final page of this Report for additional important information. Date of Death: 01/13/2013 Account of: HANS S RON.BERGER Valuation Date: 01/13/2013 Account: 62681292 Processing Date: 09/27/2013 Number of Securities: 12 File ID: 62681292 Shares Security Mean and/or Div and Int Security o: Par Description High/Ask Low/Bid Adjustments Accruals Value 11) 50 VISA INC (928260839) TOM CL A New York Stock Exchange 01/11/2013 161.25000 159.50000 H/L 01/19/2013 161.81000 159.55000 H/L 160.527500 8,026.38 12) 100 WELLS FARGO & CO NEW (999796101) COM New York Stock Exchange 01/11/2013 35.18000 39.53000 H/L 01/19/2013 35.06000 35.52000 H/L 39.822500 3,902.25 Total Value: $105,978.00 Total Accrual: $0.00 Total: $105,978.00 Portfolio Endnotes This Estate Valuation Report (the "Report") was produced by Stifel Nicolaus at its client's request using information provided by the client. The Report was calculated and produced using the EstateVal system, a product of Estate Valuations & Pricing Systems, Inc. The pricing, valuations, and calculations provided by EstateVal come from sources believed to be reliable, but the accuracy of same is not guaranteed or warranted by Stifei Nicolaus. Users of the Report should take special note that features of certain securities (including, but not limited to, securities having a "death put" feature, variable rate securities, treasury inflation protection securities (TIPS), "Z Tranche" bonds, "Builder" bonds, defaulted or impaired bonds, and "illiquid" or "thinly traded" securities) may result in such securities not being valued or valued correctly for estate tax purposes. This Report is not intended to provide, and may not be interpreted as providing, tax or legal advice. All users of the Report are urged to consult a qualified attorney or tax professional for assistance in interpreting and confirming,the accuracy of the Report and applying the information contained herein toward their specific circumstances. Page 2 This Report was prepared by Stifel Nicolaus, from information provided by its client, using the EstateVal system, a product of Estate Valuations & Pricing Systems, Inc. Stifel Nicolaus, its employees and financial advisors are -.at estate planners and cannot provide tax or legal advice. Please consult a qualified attorney or tax advisor regarding the information contained in this Report. Please review the final page of this Report for additional important information. ;; '§ w 0 m \ @ $ 2S � � « 2 m q ( # V7 . ( � $ , 0 E % . \k \ \ ( k \ \\\ ! / \ ) \ § u zz ae § - > § t a , a : L) ?_ § 2 u \ . d j / . , ! 22 \ � / . 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Deb to Avabble Credit Rego _ _ Payment it Inqu 5to7/Bankruptcies stilt options check specs Mileage: 18000 ] Change Like tMS wr r/ ✓ Credit I wiles Trade-In Value Private Party Value ^ see What Influences Yom credit Score when trading in at a dealership when selling the car yourself a>r Print Report WO enrollment In keecrecitscore_rorp- Excellent — __-- - -- - . $11,550 Shop for your next car Price a new car a msemeht why aaa? Very Good -$11,225 Instant Trade-In Offer Good Get the offer 1 t � I+ $11,000 ita � l� C,EL_ RAT, Fair [ ,S' ••-", $10,100 �r Own it? Love it?Tell Us. write a review �I II r Verify Condition Track is car's . . I_...i'l.` .. ... . it aLTC.� �i. Values valid until Sell your current ear Place an ad 08/29/2013 A,li merit why ads? (uptlated weekly) Helpful Resources from KBB.com Apply for Financing Get Selling Advice Check Local Prices Lock in your loan,then See the pros and cons See what people near you CARCHEX is the company you can trust shop for your next car. of different ways to sell. are asking for their cars, for your EXTENDED AUTO WARRANTY Free Instant Quote Lean Mom Review Benefits Cars for Sale Get a Used Car Report CARCHFck near Camp Hill ,,n© !L wstomera qet Stee oawnm yw r�9'lrM awnti,n,mrm me,-Kell, ruir „ 2066 Buick Lucerne Get the Information You Need on This v 2006 Buick Before You Buy 14 for Sale Near You View aJ,,,,r merit why aas? Go o o ro`61emTB-u'y'ar?'URLTFrt'fE report today and run VINs as y6@%glJi ryliwetl Cars I My Saved Cars Save car I http://www.kbb.com/buick/luceme/2006-buick-lucerne/cx-sedan-4d/?vehicleid=100&inten... 8/27/2013 jThrivent Financial for Lutherans- January 15, 2013 Estate of Hans S Romberger 5225 Wilson Ln Apt 3139 Mechanicsburg PA 17055-6669 Subject : Estate of Hans S Romberger IRA Contract LC4749976 To Whom It May Concern: Thrivent Financial for Lutherans is required by the Internal Revenue (IRS)to report the contract value as of the date of death to the estate of Hans S Romberger. The IRS form 5498 will be sent to the above address in January of next year. Form 5498 will report the fair market value of the IRA plan to Hans S Romberger's estate. This letter should be retained for income tax purposes when filing the decedent's income tax return. Date of Death: 01/13/2013 Contract Value as of Date of Death:" $64,696.18 If you have any questions regarding the above information, please contact your Financial Associate, JAMIE C FRENCH, whose telephone number is 717-525-9535. You are also welcome to call Thrivent Financial for Lutherans at 800-847-4836. Sincerely, Death Claims Death Claims & Services Product Services Department, FSO Cc : JAMIE C FRENCH 0165 43402.00 Hans S Romberger , deceased, Contract#LC4749976, CIF#500947438 Deceased's Customer ID: 500947438 TO OPEN - INSERT FINGER AND CAREFULLY SLIDE UNDER THIS EDGE .gj, t U.S. Office of Personnel Management Retirement Programs APSES PQ4r Retirement Operations Center ;r.. O 4CF Boyers,PA 16017 aa> as>a OFFICIAL BUSINESS W 00.46 PENALTY FOR PRIVATE USE, $300 02 iM ' i' 0004292546 JUL 25 20 FORWARDING SERVICE REQUESTED MAILED FROM ZIP CODE i 60. ROBERT A ROMBERGER II EXECUTOR ESTATE OF HANS S ROMBERGER 6109 SMITHFIELD ST HARRISBURG PA 17112 i�'. �:��:�:�? �:i:_;z ttllltllthihlhutlhPttllil11111111ttlllut�1111n11.II!Ilttll w"MElm a`rl y` v V .. y f J` rr ;% �,- r V lV V t 1> ezS .. ! . !. { ,rvt � � ) >t?)J, . )1 r 3 .i.r. S •r ) �i�,i]1� � y r\y'•*v r�'' ` ,yid r�1 j��,,,r,�'`! �yi�'i' � •• y��yil Yi �� ,iSSY,""]d•. V O rylY.�� i�.1 �f" � i`' �1; � r �` ' . irT �` tl; AD �r � r yr y- •� r � . >.r rt �t a J" ,i { / y 11!ynaa?�.�}rr•l�_�; 7 1� ���y���. �+;:•Y�t�i �,. .yY'�'l`:� �.:Y, .�-`f. �✓. .�`I}�?l`a - . . ,`'�r �� ,�iS:y1 l`. ���, �'�.+!'y���„j`:^i}�i,+ �'.�`a�r �'y'+�'�y .. • �y�°”t"YY' �!"t•''�•>���`'���'� �':I`� �'�2�` . 3 � )�. )lj .. .. S�j�, Ji )� .�) .. l��i •3` .f )`� .. h' . 9`y�� :i•S� . !�i�lf�) ai•3>.}}•er.,i�•S�lr, f.1���•i!f3i1>y�.l.3 �Y,;_/.s,?•r„ll'�'?S� � q''1�r`i.ly�lSi„i y�rAr.�e1'�r�•rl'.y�r:r.l'.r�r l '�)�E� s. ` — _ —� `- - -� L - - - FINAL STATEMENT OF LUMP SUM DEATH BENEFIT PAYMENT You are entitled to a lump sum payment because of the death of a former employee. This payment, shown in Block 5, covers only benefits due from the Civil Service Retirement and Disability Fund and consists of any unused contributions the former employee made to the Fund or any accrued annuity payable at the time of his or her death, or the Basic Employee Death Benefit payable to a surviving spouse under the Federal Employees Retirement System 1. Name of Deceased Federal Employee 2. Claim Number 3. Data of Birth 4. Date ROMBERGER HANS S CSF 3490213 01/31/34 07/25/13 S. You Will Receive a Lump Sum Payment For 6. To Be Sent By 7. Interest(Included in Item 5) a. Tax Withheld $ 1604. 83 00/49-/43 -: $. NONE $ NONE.._ .. . S.Remarks YOUR LUMP SUM BENEFIT HAS BEEN .ISSUED VIA EFT AS REQUESTED ON YOUR APPLICATION.. a-n i INa See reverseaside'.for.important information. .b .�. TO OPEN - INSERT FINGER AND CAREFULLY SLIDE UNDER THIS EDGE .: U.S. Office of Personnel Management Retirement Programs SFS FAST Retirement Operations Center 5SP .pC� Boyers,PA 16017 _ O OFF I C I AL BUS I NESS 7 - QQ''Tu��eoe cs PENALTY FOR PRIVATE USE, $300 02 1M $ 00.46 0004292546 JUL 25 20 FORWARDING SERVICE REQUESTED MAILED FROM ZiPGODE !6D ROBERT A ROMBERGER II EXECUTOR ESTATE OF HANS S ROMBERGER 6109 SMITHFIELD ST HARRISBURG PA 17112 NMI i-;•1. <Y.w:�-�? :�� _� +Illlllllhliriv11111Pllllil'nilliliiliililllll,llflllhlull INS, )• �f `�1.. a) f ) . ..r 4) 4' . r) . y ism!I tit y � i � � L ��,_�� �� �yam,,`, y��� �� 1�d c�� ���►r �i{t: i.! )y�r � ,..� '3 � :'�) � f :•'��r )�. :... • 1'��.''yi'� ~.l _`�� .��`�Y.,.f..) S�' .j `�f ;�1��` �; �y 'E J',���/.�'�{�i�K �{Y I,��i�� •� { �+' * l a��� st�✓ . �'TtN�'st�;/'aKir��/.t�i" ., it l�a! rRl..n. .i1�`�'K �/11`y'i�Fk�rt��n ♦ftl�it .fl1`>#w-%!".st�'il�if,.>�e �Ats� N'11+1�w��'e♦!1�x' ii�)a. ctlt'Sr L _ _ _ FINAL STATEMENT OF LUMP SUM DEATH BENEFIT PAYMENT You are entitled to a lump sum payment because of the death of a former employee. This payment, shown in Block 5, covers only benefits due from the Civil Service Retirement and Disability Fund and consists of any unused contributions the former employee made to the Fund or any accrued annuity payable at the time of his or her death, or the Basic Employee Death Benefit payable to a surviving spouse under the Federal Employees Retirement System. 1. Name of Deceased Federal Employee 2. Claim Number 3. Date of Birth 4. Date ROMBERGER HANS SCSF 3490213 01/31/34 07/25/13 5. You Will Receive a Lump Sum Payment For 6. To Be Sent By 7. Interest(Included in Item 5) 8. Tax Withheld $ 1604. 83 00109J13 c s. NONE s NONE a. Remarks YOUR LUMP SUM BENEFIT HAS BEEN .ISSUED VIA EFT AS REQUESTED ON YOUR APPLICATIQN.. I aw See reverse side.far Important information. ,00 STATE OF Pennsylvania IN RE: ESTATE OF IN THE REGISTER OF WILLS HANS S ROMBERGER CUMBERLAND COUNTY CASE#: 21130085 STATEMENT OF CLAIM AIS Recovery Solutions,LLC,servicer on behalf of Bank of America I. hereby presents for tiling against the above estate this statement of claim in the amount of$ $7,888.25 2. The basis for the claim is account humber 5466320998957706 which was open on 5/23/1990 3. The name and address of the claimant is AISRecovery Solutions,LLC,scvlcer on behalf of Bank of America P.O.Box 248852,Oklahoma City,OK 73124 4. This claim IS NOT contingent 5. This claim IS NOT secured 6. The last payment made on the account was $ $59.49 on 3/30/2011 7. Please send payments to AIS Recovery Solutions,LLC,servicer on behalf of Bank of America P.O.Box 248852 Oklahoma City,OK 73124 1-888-221-4299 Please write the above account number on your check. Under penalties of perjury,I declare that I have read the foregoing,and the facts alleged are true,to the best of my knowledge and belief. Executed this 4 day of April 2013 AIS Recovery Solutions,LLC, servicer on behalf of Bank of America Claimant Name: Craig Smith Claimant Signature: �SBURY STATEMENT Page: 1 of 1 BETHANY ►� � ln 3"r.T ` Rq w + 151: i ' p,�.5�'�4:' male VILLAGE 413834 23934 03/07/2013 Anticipate More 325 Wesley Drive Mechanicsburg,PA 17055 n i •+r, r$° ,-i ate;,, �Sr."AR ^+93??P°'.::.-Y ,•,'��;y�yyLllie'.Date `i`�-' �g'y�S,�Amoi7n�I)Le x� Rrnoum�Fr id� �% 03/1412013 -$2,436.28 It.EX,Robert A.Romberger �� 5 id rat Nam 6109 Smithfield Street .e ee den u«,!,� �P's°j•.�'v . Romberger, Hans S Harrisburg, PA 17112 .............. .. .. ............— ---- ---— —----- - . -......----............... . . ............. .......... . .. PLEASE DETACH AND RETURN UPPER PORTION WITH YOUR REMITTANCE Romberger, Hans S Independent Living 03/07/2013 £S� fit::bti .aCa1 d• Det'ct7' on =.,"• ";f"; 3FtCt5'�7'� U7,,jj t dU�tit '$�",Ja'x xNet` :at y+".`'zK,0r.,BUFR'M'y"�*i F�oiTri .s''"sift 'iG-tir.6i7"Cb �•y �'>b&'?* r`2 '.y '9��,`' C. .::CharTcrs tTOedits±�€KIM ,S:;ir T�°-i: ;.:;':.+'•.= .'i tiC,+du*�.i�':uSYx:., v,. � aiY/`-90:4Ft'�aSRESIDENit ESPONSIBINTOY; fK 41:is�C'.'+?L%Xrsht°e+#;9"a'.a'x�:E>�'.rGii':'7tik+7F_r.^�t ni'{•�'9 01/31/2013 Balance Forward $2,363.60 Payment Received(2113/2013) -2,436.28 -$72.68 Payment Received(211912013) -2,363.60 -$2,436.28 Please contact Jennifer Black at 717-591-8029 with billing questions.Thank youl cxyy':TOTAL ki •i ,�.'.';. ; Fbin.l�,.` i xir�fw� >-r��nyF s' t. 'r•.�..._..n a nt tit'- i.x ..Ave' �e d3`kC{7�n�k�M���. � , tr'j1Y';. �;4'T�+�kr� - ��:s � '.:�.`.�T� �s.:��. -$2,436.28 TOTAL RESIDENT,'RES . O , SIBILIT� <<, • / STATEMENT OF ACCOUNT C�r�� CCRX OF BETHANY VILLAGE 69906 SNOWDRIFT RD PAGE: 1 of 1 ALLENTOWN,PA 18106 ACCOUNT NO: 7002-261 RETURN SERVICE REQUESTED 39729 INVOICE NO:DX NO: OPDX K0PDX44 INVOICE DATE: 12131112 2807 0101 FACILITY: 7002 BETHANY VILLAGE IND LIV PHONE: 877-670-6323 PATIENT NO: 261 You may also view/pay your bills at: PATIENT NAME: ROMBERGER, HANS https://myomniview.omnicare.com AMOUNT DUE: 20.56 0.00 ulrlgglmhhlhl611inhlllhlrrrruyldltrrldl�llurl HANS ROMBERGER 5225 WILSON LANE DUE DATE: 01/25/2013 APT 3139 MECHANICSBURG, PA 17055-6669 n I , AMOUNT DUE: 20.56 �I L/`� 39729-TOS09SXQ7000058 3OS09VJ4G:1.1 KEEP TOP PORTION FORYOUR RECORDS-RETURN BOTTOM STUB WITH PAYMENT ���IIV���IIDIN���I�IInII��IIDIID®I�® ROMBERGER, HANS 7002 BETHANY VILLAGE IND LIVING ACCOUNTNUMBER • r 7002-261 12/31/12 DATE RX NO. TRANS DESCRIPTION - PHYSICIAN NDC NO. QUANT AM NT TYPE 12/20/12 6357 LOCK PAYMENT - THANK YOU - Lockbox 20121220091504 83.19 000196071 r P - 12/05/12 R70006287 CHARGE KLOR-CON M10 10MEO TABLET-ER ( OP YO _ A t�yyy"'t EHGARTNER 00245.0057-11 90 -. 3.57 RX 12/05/12 R7000237 CHARGE LOSARTAN POTASSIUM 50MG TAB P11—� O,f;�A'6Vy a`? � ` EHGARTNER 00093-7365-98 30 2.41 RX 12/13/12 R7000592 CHARGE SIMVASTATIN F/C 20MG TABLE tiOAt<�9 q y p,. EHGARTNER 16714-0683-03 30 1.10 RX 4 12/73/12 R70005928 CHARGE METOPROLOL SUCCINATE F/C.25�G=TABS5R 7411;,,A:�bRRY�,rt EHGARTNER 64679-0734-02 15 1.89 RX 12/13/12 R7000592 CHARGE CLOPIDOGREL 75MG TABLET�(COi Yxy`> �r''"+Tu 'EHGARTNER 00093-7314-98 30 8.01 RX 12/13/12 R70002893 CHARGE BUM cx ETANIDE 1MG TABLET (COPAV1Gtr is ei't dJ:HGARTNER 00093-4233-01 45 1.20 RX 12/20/12 R70004484 CHARGE GLIPIZIDE ER F/C 10MG TABILET`(f,,DF.(1 � `y"��; i,*"'-aT,, EHGARTNER 00591-0845-01 30 2.40 RX (a z Messages FINANCE CHARGES are calculated eta MONTHLY PERIODIC RATE OF 1.50%(ANNUAL RATE OF 18.00%)based upon an unpaid balance 9utstaodirtg,30 days or nnore PREVIOUS BALANCE CHARGES FINANCE CHARGE TOTAL CHARGES PAYMENTS & CREDITS AMOUNT DUE 83.19 20.58 --- - - - - -0.00 - ' 103.77 -- - - -83.19 20.58 L slate-- Manage your account online: - customer service Additional contact tram CHASE l.1 www.chase.conVeredilcards 1-800-9452000 information on back y ACCOUNT SUMMARY PAYMENT INFORMATION Account Number: 4417128686554005 New Balance $303,71 Previous Balance ,,111 b7 85 Payment Due Date 02102113 Payment,Credits (` ql $0.00 Minimum Payment Due $55.00 Purchases $0.00 Late Payment Warning: If we do not receive your minimum Cash Advances ` $0.00 payment by the date listed above,you may have(o pay a late fee of up to$35.00 and your APR's will be subject to ink ease to a 1 Balance Transfers $0.00 maximum Penalty APR of 29.99%. Fees Charged +$25.00 Minimum Payment Warning: If you make onI(y the minimum Interest Charged +$2.86 payment each period,you will pay more in inter4st slid it will take you longer to payoff your balance. For example: New Balance $303.71 1 Opening/Closing Date 12/06/12-01/06/13 If you make no You will pay off the Ancl you will end up additional charges balance shown on paying an estimated Total Credit Line $21,000 using this card and this statement in I total of... Available Credit $0 each month you about... Cash Access Line $10,600 pay"' ' Available for Cash $0 Only the minimum 13 months $325 paymon[ , If you would like information about credit counseling services,call I� 1-866-797-2885. ;! ' d Please pay the Minimum Payment shown at the top of this j statement. It includes any past due amount.The minimum payments used to calculate the estimates shown in the above table '—do not include pasfdua amounts-- 1 ACCOUNT ACTIVITY , Date of @ Transaction Merchant Name or Transaction Description G $Amount RM OV02 LATE FEE 25.00 TOTAL FEES FOR THIS PERIOD $25.00 1 01/04 PURCHASE INTEREST CHARGE - 2.86 TOTAL INTEREST FOR THIS PERIOD $2.86 '-aura _r Total fees charged In 2013 - $25 00 Total interest charged in 2013 $2.86 Year-to-date totals reflect all charges minus any refunds applied to your account. INTEREST CHARGES Your Annual Percentage Rate(APR)is the annual interest rate on your account. Annual Balance Balance Percentage Subject To Interest TYPe_—_ _- - _ Rate-(APR) -_._......._._ _._ -Interest.Rate- -- _ Charges.. ._. .. ..... ...... �Purchases 11.99%(v) $280.44 $2.86 Cash Advances 19.24%(v) -D- -0- 0000001 FIS33338 D 6 000 N Z 05 13MIM5 Page 1 of 2 06598 MAMA 14305 00410000060461430501 X .-.. .. . ... k w Home`Ihstead DETAILED INVOICE a Service For : Hans Romberger(l) GtT f 1-erto`t Z Billed To : Mr.Hans Romberger 5002 Mechanicsburg,Street Invoice#: 1224-1212-2 Mechanicsburg,PA 17050 Invoice Date : 12/31/2012 (717)731-9984 Service Period :Dec 16,2012-Dec 31,2012 www.HomeInstead.com 12/17 8:30am 11:30am Normal Baldwin,Nancy 2.00 Hourly Service,Level 1 3.00 $19.95 $59.85 12/20 8:45am 11:45am Normal Baldwin,Nancy 2.00 Hourly Service,Level 1 3.00 $19.95 $59.85 12/24 9:15am 12:15pm Normal Bell,Beverly Hourly Service,Level 1 3.00 $19.95 $59.85 12/27 8:45am 11:45am Normal Baldwin,Nancy Hourly Service,Level 1 3.00 $19.95 $59.85 T'ot QO NNS 21 _„ 23„„„�. Miles: 4.00 C4 $0.59 - $2.34 Miscellaneous Charges: _ $0.00 Additional Charges/Credits: — $0,00 CurieoflnvoieeTotal- S241'.74 Total Amount Due: $241.74 Due Date: Due upon Receipt *All overdue Invoices an Subject to an 18%Annual Service Charge PLEASE DETACH AND RETURN UPPER PORTION WITH YOUR REMITTANCE Romberger,Hans S Independent Living 01/11/2013 -.... °'.Date'. - I 'Description' r" - Units' - Unit Net..-= - * Balance :F.rom---. . Thrdu hr....'. - Cost 'Char es� 'Cred@s�- ' RESIDENT RESPONSIBILITY 11/30/2012 Balance Forward $2,320.41 Payment Received (12/14/2012) -2,320.41 $0.00 01/01/2013 1/31/2013 Monthly Service Fee 1.00 Month 2,253.00 2,253.012 $2,253.00 12/01/2012 12101/2012 Dining Charges Dining Charges 1.00 Each 8.47 8.47 $2,261.47 12/02/2012 1210212012 Dining Charges Dining Charges 1.00 Each 13.77 13.77 $2,275.24 12/04/2012 12104/2012 Dining Charges Dining Charges 1.00 Each 9.52 9.52 $2,284.76 12105/2012 12/05/2012 Dining Charges Dining Charges 1.00 Each .9.53 9.52 2,294.29 12/06/2012 12/06/2012 Dining Charges Dining Charges 1.00 Each 7.41 7.41 $2,301.70 12107/2012 12/0712012 Dining Charges Dining Charges 1.00 Each 7.411 7.41 $2,309.11 12/08/2012 12/0812012 Dining Charges Dining Charges 1.00 Each 9.5 9.5 $2,318.63 12/11/2012 12/11/2012 Dining Charges Dining Charges 1.00 Each 8.4 8.4 $2,327.09 12/15/2012 12/15/2012 Dining Charges Dining Charges 1.00 Each 8.4 8.4 $2,335.56 12/16/2012 12/16/2012 Dining Charges Dining Charges 1.00 Each 13.7 13.7 $2,349.33 12/19/2012 12/19/2012 Dining Charges Dining Charges 2.00 Each 7.41 14.81 $2,364.14 12119/2012 12/19/2012 Beauty/Barber mens cut 1.00 Each 14.5 14.5 $2,378.64 12/21/2012 12121/2012 Dining Charges Dining Charges 1.00 Each 8.4 8.4 $2,387.11 12/2212012 12/'22/2012 Dining Charges Dining Charges 1.00 Each 8.4 8.4 $2,395.57 12/2312012 12/23/2012 Dining Charges Dining Charges 1.00 Each 13.7 13.7 $2,409.34 12/26/2012 12/26/2012 Dining Charges Dining Charges - 1.00 Each 7.41 7.41 . _. . $2,416.75 12127/2012 12/27/2012 Dining Charges Dining Charges 1.00 Each 9.53 9.5 $2,426.28 1/01/2013 1/3112013 Storage Rental 1.00 Month 1 0.0c 10.0c $2,436.28 If you have any questions regarding this statement, please contact Jennifer Black at 717-591-8029.Thank you! TOTAL TOTAL RESIDENT RESPONSIBILITY $2,436.28