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Home My WebLink About02-0407PETITION FOR GRANT OF LETTERS OF ADMINISTRATION Estate of ~1 ~ h n ~ K I e n I~ also known as Deceased. Social Security No. _ " No. ~~ -~~-7 y 7 To: Register of Wills for the County of Cumberland in the Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older, appl i-ed for letters of administration on the estate of (d.b.n.; pendente liter durante absentia; durante minoritate) the above decedent. Decendent was domiciled at death in i.1 /n B ^ ~ Q/I d Cou ty, Pennsylvania, with ~- last family or principal residence at So ~A2 2 E'~. m~l'hAn/IBS-bwr~7 ~ ~ ~r}yPdP~ 7pl(~I~St street, number and municipality) V Decendent, then _ oft! years of age, died _~'~C~ as ,~OOa ~_ at ~112~~<~l L°~fle~ ~~ ~r-i1S~~VAt~llt ~(-ps~i~A I ~ . Decendent at death owned property with estimated values as folllows: (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: Petitioner after a proper search ha ~ ascertained that decedent left no will and was survived by the following spouse (if any) and heirs: Name ' Nc~ 1 :-tl Relationship ~i2 ~. xes en~~ee Z' f ' '~ cl~r' L"~ /11rdi ~~ THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the appropriate form to the undersigned. U N ~~~ / b y C G O cd "«. v, p.., a~ w ~ O C C oA $ ~~ a, /~-s9-~ OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA COUNTY OF CtiI[nberl anti The petitioner(s) above-named 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 representative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. _~ Sworn to or affirmed and subscribed before me this 22nd day of Lewis ss ~l D~~~. ~-aa-~a. ii~`~~-- NO. 21-2002-407 Estate of John F. Klenk ,Deceased GRANT OF LETTERS OF ADMINISTRATION ~. a ~s on AND NOW April 24 , ~ 2002 in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that John F. Klenk is/~ entitled to Letters of Administration, and in accord with such finding, Letters of Administration are hereby granted to Francis FC.lenk in the estate of John F. Klen Register of Wills Mary C.Lewis Letters of Administration .... . Short Certificates(1~ ... , . , . , . . Renunciation .1 ............... JCP TOTAL Filed Apxil~24, . 2Q02.... A FEES $ 18.00 g 30.00 $ 5.00 $ 5.00 $ 58.00 .D. ]~_ Rosemary Ferrino # 46773 ATTORNEY (Sup. Ct. I.D. No.) 2250 Hickory Road, Suite 300 ADDRESS Plymouth Meeting, PA 19462 PHONE (610)834-6270 MAILED LETTERS TO A'I'iiORNEY - ROSENIARY FERRINO 4/24/02 105 R(15_ RFV 4/R~ This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent''filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. M705. tit Rev. 1791 TYPE/PRINT IN 02-1342 PERMANENT BLACK INK 0 J a 0 a Z G. Fee for this certificate, $2.00 P 8203527 No. j Local Registrar Date COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH (Coroner) NAME OF DECEDENT (Fxq, MYlde, Leq) SE% SOCb4 6ECURITV NUMBER DATE ff DEATH (MOnm, Dag Pearl ,John F. Klenk ,.~yAlr 3. /g/-~~-~S9S' .. 22 Mar 2062 AGE (Lass &ruWay) UNOERIVEAR UNDERIDM DATE OF BIRTH BIRTHPLACE ICpyeM PLACE OF DEATN(Cneck ady one-sae prgnrcliansmaYrer yqe) Mdmro o.y1 Hour Mlnuln (MOnm, Day NSer) Slide or FOrrrgn COUdryj HOSPITAL: OTHER: Inp01Mn1 L7 EWdApgNM ^ DOA ^ 4 ^ S re ^ R ^ 7 Yn. s. `i 4 s. // / T 1.'A R ~ ey periCe ( pec~tyl Ha ' COUNTY OF DEATH - CRY,BORO.TWP OF DEATH FAGLITY NAME(Y na mstsueon. give ed aM armba) VMS DE EDENT OFIB NK:ORKiiN7 RACE-Amercen Indian, BlACk, Whxs, etc. (Spcc'M ~J V N ^ N C b a n u an. YM. WcM Philadelphia Philadelphia Medlca] College of Pennsylvania Hospital Mexlran, puma Rican, alc. ~ fe ab. b. 10. DECEDENT'S USUAL OCCUPATION KIND OF BUSINESSANDUSTRY WAS DECEDENT EVER IN DECEDENT'SEDUCQION MARITAL STXIUS•MrriW SURVIVING SPOUSE IGve kiMdwod dna don~qe nroq U. S. ARMED FORCE ? d Never MerrW, Widowed, pl wne. give maiden names eciy) DrvacW(S l ~ C Y p emanury/SaCaWery dwakinpMa;ddrwlusergxe0) E o •W ~^ No ~L 11 ~ ~ I7 ~1/tL ri4rT'•O // ,r 1012) ll•a5y) t 13. t . ~t / ,ArR,i: ~O 1 . SS (SV•q, City/bwn, Slats. Lp COde) ILINO ADDR DECEDENT'SMA E DECEDENT'S /J n ~ d i ~/4~ / ry C'^ m9 Sl tT Y d dem W 77 / ~. A w ~ So ~ P~yRf~[ • Q ~e ~Q G(,Q f ree e. ala ~~y e. w. e ESIOENCE iKe«,!a.Y'%eSBe! 46 PiP. ~ T S ~ °~°"'~ ~j a C '°w"q"P' ' ' L ~ `~ "~ ~ ,s , o o ~rM6 •v~ 0 .al a~ylbaa ~ ~P ,Td.^ id q~ a.l ,Tb.caal FATHER'S NAME (Firq, Midde, 11a0 MOTHER'S NAME IFkq, Mid4a. MaidYl Sanemel u. ~yf/.Y 1~,J u. A ~ c.c INFORMANT'S NAME (TypaPrinO I NFORMANT'S MAILING ADDRESS (Seep, OpY/ylwn, Slge, Zip Codes METHOD OF DISPOSITION DATE OF dSPQSITION PLACE OF DISPOSRION-NuwdCemwry, CrtmWOry K)H-Cpyl6wn.9sge.ZpCoG BWW 117 Cremelldn^ Remdvq lrom Slge^ e (MOnm. D aY. Yearf apMrp4ce ^ ^ Donlf OIMr(Spxiyl 1 w 7 ..J /pjT/(~0~~ E ` / / /~ y- 1 . ! /' YL/f ~Mrf "7~ . /-P~',~~// /!J/'~ -A SIGNATURE OFFU RK SERVICE LICE PERSON ACTMIG AS SUCH LK:ENSE NUMBER NAME AND ADDRESS OF FACKRY Ne,'L F••+~,'e.Pq! s/v •Y! 1r ap•me Saes ar•J' rnerUlylep To1M bW Ol myprowiedpe,Mgnaaurtedglhe lime, dale end place gged. LK:ENSE NUMBER GATE KiNEO ien b rrq evliMbM q b d.qn to (Spnalae and Tale) (MOrdn, Oey. Year) ceniy caws d a•ln. 33b. lac. gems 2l-20 muq WCOngMed by TIME OF DEATH DATE PRONOUNCEODEADIManm. Day, Year) WAB CASE REFERRED TO ME LE%AMINERK:ORONER4 ~°`~°^w"°Pr°^°'"KiOie'" 11:40am 22 Mar 2002 v„ Na^ EI. M. ] . ZT. PART 1; Enter IM dl•eeW. IryrxW a damp4delbna whidl Guaed the deem. Do rot emer Ina erode of dYinQ, wcfr as cardiac w respkalory snap. Mocpa Man IaiW1e. ~Approximw PART B: Other aipnpkanl cdndliona conlri0urinp to degn, ba Lipony Ow nuts on eachane. rlrKervgwlwe.n rolraauninq in Ile undeMinp cause DivanNPMTI Orleel •Ild dwm BM/EOIATE CAUSE IFxv+l ; d,~a~a«,o„dl~a, MULTIPLE INJURIES leswi~ ~n daatlp ---. 1. DUE 70 (OR ASACONSEQUENCE OF): i s.qu.mie•ywrx,mMim. n__-- ___ _.- -~__--._ r --- - DUE IOIOR ASACONSEOUENCE OF): i1My,kadrploimnetliala cause. Eder UNpERLYBW CAUSE IUsaasea uyury c. mu xulalBd events DUE TO (OR AS A CONSEQUENCE OF): . e%m~nv ardeaml LAST ~ d. VMS AN AUTOPSY WERE AUTOpSVflNDINOB MANNER OF DEATH DATE OF INJURY TIME OF INJURY INJURY AT WORKS DESCRIBE HOW BIJURY OCCURRED. PERFORMEOT w~wLA~eL~EKJ~IJ~~sE IMOdn.Deyrea) PEDESTRIAN STRUCK HY A oFDEATHy Nal°rq ^ "°r"ia;" ^ 22 Mar 2002 9:16am Yet ^ I''a~ MOTOR VEHICLE 77~~ 7y~ (F~ ~B Accided L'J Pendirp lnWgipalian ^ .~, No^ Yxs 'iJ ,, No ^ YN 'Ll PLACE OF INJURY-Ainww.lerm, grM,tae,ory, opice L ~1°B!1(~L'?O1L'~~P11~WYN I.N. Suicide ^ CauM Ml be dgerminad ^ 6WIdinO. gc.IfirracJl„_Wa PA 19004 gala Cynwyd 3H. t4b. 2i. y 30e. ~~~~~JJ++++ , CERTIFIER ICtwck rely Deal SIGNATURE AN A OF CE ER `CERTIFYBIOONYSIGAN (Phyaxw~ caUlyirp Cause of death when anomer phys~can has pronounced death and completed Item 27) ^ To Me beet of my KrgeMdpe, dNm oceunM dn• b IM nu•Nal erw menwr u added ..................................................... 10. LICENSE N BER DATE SKI M Yeayv ~ ~ 002 'PRONOUNCWGAND CERTIFYING PMYSKAAN IPhYSCien bdn prorouncup deem end wnsyinp mcauee ddealh) end tlw b IM eawelal and menwrM W W .......................... ^ dNM O•Crund e11M 1MU deU arts p4ee To me baN O/ my kndMedpa 31 316. , , , , ' NAME AN DDRESS OF WHO COMPLETEDCAUSE OF DEATH (Item 2Y}f[~[riR(7>).lyng M. D. 'MEOICALE%AMINER/CORONER On In. baaAa a eAaey11M1Wa argla InvaHlCNlon, In my oplnbn, Wssa occurred al,na drlle, 0•Le, end Place, and dw to tM uueep) and il g ens ~ c Fe} 1 ow u ~~ l m.nn.r as q.Ia .................................................................................................. e University Aven 3 7L. 33. , ~ r ti, REGIS RAP'S SKiNAURE AND NUMB~R ,Day, Peer) DATE FI D ( Ma pn ~L ' ~ ~I~. ~ y - . <~ ~P ~~~~ u. N.. CERTIFICATION OF NOTICE UNDER RULE 5.6 a NAME OF DECEDENT: John F. Klenk DATE OF DEATH: March 22, 2002 ADMIN. NO.: 2002-00407 To the Register: I certify that notice of beneficial interest 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 July 31, 2002: NAME ADDRES S Francis G. Klenk 504 Partridge Court, Mechanicsburg, PA 17050 Mary Agnes Klenk 504 Partridge Court, Mechanicsburg, PA 17050 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: None Date: August 1, 2002 O'BRIEN & RYAN ~-~ ~ ROSEMARY R. RRIN Attorney I.D. No. 46773 2250 Hickory Road, Suite 300 Plymouth Meeting, PA 19462 (610)834-6270 Capacity: Personal Representative X Counsel for Personal Representative 't" IN RE: JOHN KLENK, DECEASED IN THE COURT OF COMMON PLEAS ORPHANS' COURT DIVISION CUMBERLAND COUNTY, PENNSYLVANIA N0.21-2002-407 ~'~.~ CITATION ~' ~"`"" WE COMMAND, you that laying aside all business and excuses whatsoever, you be and appear in your proper person before the Honorable Judges of the Court of Common Pleas, Orphans' Court Division at a session of the said Court there to be held, for the County of Cumberland to show cause why THE COURT SHOULD NOT APPROVE THE SETTLEMENT AND DISTRIBUTION OF SET`CLEMENT PROCEEDS IN ACCORDANCE WITH THE PROPOSED ORDER OF DISTRIBUTION CONTAINED IN THE PETITION. COPY OF PETITION TO BE SERVED WITH CITATION. SERVICE TO BE EFFECTIED BY CERTIFIED MAIL, RETURN RECEIPT REQUESTED ,UPON THOSE PERSONS IDENTIFIED ON THE ATTACHED LIST OF INTERSTED PARTIES. CITATION RETURNABLE THE 30TH DAY OF OCTOBER 2002, AT 1:30P.M. IN THE ORP'HAN'S COURT DIVISION ROOM CUMBERLAND COUNTY COURT HOUSE, CARLISLE. PENNSYLVANIA Witness my hand an official seal of office at Carlisle, Pennsylvania, this~~ ciay o,t?O~L. Clerk, Orphans' Court Division Cumberland County, Cazlisle, PA My Commission Expires on the 1St January, a AIN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHAN'S COURT DIVISION NO.OC-02-00407 ESTATE OF JOHN KLENK, DECEASED „ r+ e'' PETITION FOR CITATION TO AUTHORIZE SETTLEMENT OF WRONGFUL DEATH CLAIM PRELIMINARY DECREE AND NOW, this oZ~ day of , 2002 upon consideration of the annexed petition, a Citation is hereby awarded to all interested parties to show cause why the court should not approve the settlement and distribution of settlement proceeds in accordance with the proposed Order of distribution contained in the Petition. Copy of petition to be served with Citation. Service to be effected by certified mail, return receipt requested, upon those persons identified on the attached list of interested parties. Citation returnable the ~_day of 2002, at ~,~.M. in the Orphan's Court Division Room ,Cumberland County Court House, Carlisle, Pennsylvania. BY THE COURT, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHAN'S COURT DIVISION NO.OC-02-00407 ESTATE OF JOHN KI,ENK, DECEASED PETITION FOR CITATION TO AUTHORIZE SETTLEMENT OF WRONGFUL DEATH CLAIMS AND DISTRIBUTION OF SETTLEMENT PROCEEDS INTERESTED PARTIES: Francis G. Klenk and Mary Agnes Klenk h/w 504 Partridge Court Mechanicsburg, PA 17050 Ana c% O'Brien & Ryan, LLP 2250 Hickory Road Plymouth Meeting, PA 19462 2. Allstate Insurance Company Market Claim Office 6345 Flank Drive Harrisburg, PA 171 I2 c% Tim Shaffer, Claims IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHAN' S COURT DIVISION NO.OC-02-00407 ESTATE OF JOHN KLENK, DECEASED ~- - -ORDER AND NOW, this Q~ ' day of ~~~X~'r , 2002, upon consideration of the annexed petition, it is hereby ORDERED AND DECREED that Frank Klenk, as l3xecutor of the estate of John Klenk, Deceased is authorized to enter into a settlement with Allstate Insurance Company for the gross proceeds of $500,00.00. Allstate is directed to forward all settlement drafts or checks to counsel for Petitioner for proper distribution. It is further ORDERED and DECREED that the settlement proceeds are allocated as follows: 1. To: O'Brien & Ryan, LLP (costs) 2. To: O'Brien & Ryan, LLP (counsel fees) 3. Wrongful Death Claim i. To: Frank Klenk, parent ii. To: Mary Agnes Klenk, parent 4. Survival Claim $ 1,703.44 $ 63,707.00 $ 217,294.78 $ 217,294.78 i. To: Frank Klenk, Administrator of the Estate of ,, 7ohn',~lenk, Deceased $ BY THE COURT, - ,- 7. 0. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVAN[A ORPHAN' S COURT DIVISION NO.OC-02-00407 ESTATE OF JOHN KLENK, DECEASED PETITION FOR CITATION TO AUTHORIZE THE SETTLEMENT OF WRONGFUL DEATH CLAIMS AND DISTRIBUTION OF SETTLEMENT PROCEEDS TO THE HONORABLE JUDGES OF SAID COURT: Petitioner, John Klenk, as pazent and Executor of the estate of Jolin Klenk, Deceased, through his attorneys, O'Brien & Ryan, LLP respectfully represents that: The Decedent, John Klenk, age 20 died on Mazch 22, 2002. The cause of death was multiple injuries to decedent, a pedestrian at the time, from being shuck by a motor vehicle. 2. Decedent was never married, and died intestate, survived by his parents Frank and Mary Agnes Klenk (as well as three siblings). Petitioner is Frank Klenk the decedent's father, who was appointed Administrator of the Estate of John Klenk, on April 24, 2002 by the Register Of Wills of Cumberland County. (Decedent's mother, Mary Agnes Klenk rescinded her position to serve as administrator) A copy of the Decree of the Register is attached as Exhibit "A." 4. The parties-in-interest in this case aze: A. Mazy Agnes and Frank Klenk (petitioner herein) pazents and intestate heirs of decedent residing at: 504 Partridge Court Mechanicsburg, PA 17050 B. Allstate Insurance Company Market Claim Office 6345 Flank Drive Harrisburg PA 17I IZ c% Tim Shaffer, Claims 5. Petitioner, individually and as Administrator of the Estate of Decedent, gave notice to his insurance carrier, Allstate Insurance Company, of his intent to proceed with the institution of a wrongful death and survival action on behalf of himself ,his wife and the Estate with regard to the underlying tortious conduct which caused the death of the decedent John Klenk, but no separate action or summons has been filed as of this date. 6. Petitioner had contracted with Allstate Insurance company for the provision of Underinsured Motorist coverage under policy 1554339489-b27 and 1554339471-b27 in the total amount of $500,000.00 for any injuries sustained by the insured's covered individuals which included his son, John Klenk. 7. Allstate Insurance Company recently gave notice to counsel for Petitioner of its intent to tender the policy limits of its UIM policy upon the execution o:f a release of Petitioner and court approval of the settlement. At the present time there is no other suit pending on behalf of the estate or Petitioner as counsel is still investigating various third party actions with regard to the damages sustained. In order not to delay the distribution of the above referenced policy proceeds, but to comply with Allstate's request to receive court approval, Petitioner brings the instant Petition and Citation. 9. The Tortfeasor driver has offered to tender his automobile policy limits of $15,000.00 in settlement of any potential third party case. 10. Petitioner has not accepted the settlement offer of the tortfeasor driver as Counsel is still investigating all potential actions and awaiting the outcome of tortfeasor's criminal charges associated with the death of decedent, including the pending charge of homicide by vehicle, while driving under the influence. 11. In accordance with Pa. C.S. 20 Section 3171, the grant of letters to Petitioner was advertised for three consecutive weeks, on August 15, 22 and 29, 2002. 12. Presently, there are no known unpaid claims raised or outstanding in the decedent's estate. 13. Counsel is of the opinion that there maybe liens that would arise under the provisions of the health insurance contracts applicable to the decedent ag<~inst any damages characterized as "survival" damages recoverable by the Estate for the costs involved in providing medical care to the decedent for the injuries that caused his death in the approximate amount of $43,067.00. No such lien will arise for wrongful death recovery by Petitioner. 14. Counsel is of the professional opinion that the proposed se;ttlement of the claims for which Allstate Insurance underinsured coverage applies is reasonable due to the following: (a) The total policy limits for Underisured coverage have been offered, with the only requirement being court approval of the disbursement [see attached hereto as Exhibit "B" correspondence of Allstate Insurance company dated August 16 and 27, 2002; (b) Although court approval in not required for the settlement of the underinsured policy limits of Petitioner's Allstate policy, court approval is sought by the Insurer as a requirement of their release of the funds; (c) Upon investigation and belief to date, the tortfeasor driver's insurance coverage applicable to the damages that would be claimed in any wrongful death or survival action is the statutory minimum of $15,000.00. [see attached hereto as Exhibit "C" correspondence dated August 22, 2002 from Geico Direct; Insurer, and affidavit of the driver, Michael Hinchey. (d) Upon investigation and verbal confirmation by the tortfeasordrer's legal counsel, Mr. Hinchey has no personal assets upon which a wrongful death or survival judgment award would be recoverable. (e) There are no other identifiable sources of recovery at this time for petitioner as either parent or executor. 15. Petitioner is of the opinion that the proposed settlement is reasonable. 16. Allstate Insurance Company does not object to the distribution as proposed [100% allocatable to Wrongful Death damages] and seeks only execution of a general release to Allstate and court approval of the distribution. 17. Counsel has incurred a total of $1,073.44 in expenses for which reimbursement is sought. 18. Counsel requests counsel fees in the amount of $63,707.00, which represents legal fees incurred between March 25, 2002 and September 25, 2002 based upon counsel's hourly fee agreement entered with John Klenk, Petitioner. 19. Petitioner requests allocation of the net proceeds of the settlement (after deduction of costs and attorneys fees) as follows: A. Wrongful Death Claim $ 434,589.57 B. Survival Claim $ 0. 20. The reason for the requested allocation in total to a wrongful death recovery distribution is as follows: Petitioner under a wrongful death action would be entitled to recover damages for hospital, nursing, medical, funeral expenses and expenses of administration necessitated by reason of injuries causing death, including the pecuniary loss of the decedent to decedent's family. The instant settlement seeks to compensate the pazents for the losses they incurred in providing for the above expenses in and for the death of their 20 yeaz old son, a healthy, promising college student. 21. Pursuant to the Wrongful Death Statute (42 Pa. C.S.S. 8301), and the Intestacy Act the beneficiaries of the Wrongful Death Claim and the proportion of thew interest , are as follows: Mary Agnes Klenk 50% Frank Klenk 50% 22. The damages incurred by the beneficiaries listed above includes the expenses for hospital, nursing, medical, funeral expenses, as well as the recoverable portions of the expenses incurred in the estate's administration. Petitioner as paent has also lost the maintenance, service, gifts and the expectations of future enjoyment of such maintenance services and gifts. 23. There is no impact on the tax Inheritance applicable to this Estate in apportioning the distribution as 100% allocatable to wrongful death as any distribution occurring in this Estate passes to the intestate heirs/beneficiaries at a rate of "0." See 72 P.S. §9:i 16 (ax1.2). "inheritance tax upon the transfer of property, from child twenty-one (21) years of age or younger to or for the use of a natural parent, ... shall be at the rate of zero per cent. " WHEREFORE, petitioner prays that a Citation be issued to the persons listed above in paragraph 4 asparties-in-interest to show cause, if any there are, why the proposed citation should not be issued providing for the settlement of wrongful death claims under Allstate's policies and distribution as provided in the proposed Order of Distribution as follows: 1. To: O'Brien & Ryan, LLP (costs) $ 1,703.44 2. To: O'Brien & Ryan, LLP (counsel fees) $ 63,707.00 3. Wrongful Death Claim i. To: Frank Klenk, parent $ 217,294.57 ii. To: Mary Agnes Klenk, parent $ 217,294.57 4. Survival Claim i. To: Frank Klenk, Administrator of the Estate of John Klenk, Deceased $ 0. Respectfully submitted, O'Brien & Ryan, LLP ~~ ~mary R rrino Esquire Suite 300, Hi kory Pointe Plymouth Meeting, PA 19462 Attorney for Petitioner Register of Wills of CUMBERLAND County, Pennsylvania Certificate of Grant of Letters No. 2002-00407 l?A No. 21-02-0407 ESTATE OF KLENK JOHN F Late of HAMPDEN TOWNSHIP , Deceased Social Security No. 181-62-6595 WHEREAS, KLENK JOHN F late of CUMBERLAND COUNTY ', died on the 22nd day of and WHEREAS, the grant of letters of administration is required for the administration of the estate. HAMPDEN TOWNSHIP March 2002; THEREFORE, I, MARY C. LEWIS Register of will: in and for the County of CUMBERLAND in the Commonwealth of Pennsylvania, have this day granted Letters of Administration to KLENK FRANCIS ( who has duly qualified as administrator(rix) of the estate of the above named decedent and has agreed to administer the estate according to law, all of which fully appears of record in my Office at CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNSYLVANIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my Office on the 24th day of Aprii 2002. egis r o i **NOTE** ALL NAMES ABOVE APPEAR (LAST, F:LRST, MIDDLE) J • • nt~srate' ~eGA~ aoo-~zz~oso eon aec~c~eo r 1 U AUG. 1.5. 2002 8:39AM ALLSTATE 1NS. Hbg, Ya. 1111'1 ""' "' ~~'~~~~~ MARKET CLAtM OFFICE 6345 FIANK ORNE tiARRi$6llFiG PA 17112 717540-7555 Fax 717540-7540 ~~ Ala®allstate.oom August 16, 2042 Jonathan C. McGovern, Esquire O'Brien & Ryan, i_L.P 2250 H'~ckvry Road, Suite 300 i'lymouth Meeting, PA 19462-1047 Reference: Your Client: Estate of John Klenk Our Claim Number: 1554339489-B27 and 1554339471-827 Dear Mr. McGovern: This letter is to confirm our settlemenfi offer of $500,0110 between the two above captioned claim numbers_ Enclosed please find the proposed UIM releases, Once this settlement has been court approved we will be in a position to release our settlement drafts. Lasty, Allstate will waive its subrogation versus Michael H inchey and consent to the settlement with his czrrier Ge'~co Insurance_ We do consent to a general release_ As always, thank you for your attention to this matter. Sincerely, ~' ._ . ~r Tun Shaffer, SCIA Staff Claim Representative :./ dLLSTATE INSURANCE COMPANY M,fRKET CLAIM OFFICE 6345 FLANK DRIVE SUITE 1400 HARRISBURG PA 171!2-2765 (u~~~~~~u~~u~~~~uu~~~u~~~~~n~~~u~~n~~~u~~~~~~~~~u~~ JONATHAN MCGOVERN 2250 HICKORY RD. STE 300 PYLMOUTH MEETING PA 19462-1047 August 27, 2002 ~i ,...... _ ..ate Loss Report Date: March 22, 2002 Claim Number: 1554339489 Date of Loss: March 22, 2002 Location: PHILA Our Insured: FRANCIS G KLENK Claimant: JOHN KLENK SB 1554339471 Thank you for continuing to work with Allstate Insurance Company on this underinsured motorist claim. Currently: 1. We aze waiting for the completion of the court action We will inform you of the status of the claim until it is concluded. We anticipate that this matter wilt be resolved in 90 days or sooner. If you have any questions, feel free to contact us at 717-540-7500. Timothy Shaffer Allstate Insurance Company GKB k: 0208270005906180 { ~~ ALLSTATElNSUR.fNCE COMPANY M.iRKET CLAIM OFFICE 6345 FLANK DRIVE SUITE 1000 HARRISBURG PA 1 7112-2 765 ~u~~~~~~u~~u~~~~uu~~~~u~~~~~u~~~~~~n~~~u~~~~~~n~~~~~ JONATHAN MCGOVERN 2250 HICKORY RD. STE 300 PYLMOUTH MEETING PA 19462-1047 ~ilista Yau re in good h: Loss Report Date: March 22, 2002 August 27, 2002 Claim Number: '' Date of Loss: 1 Location: Our Insured: Claimant: Thank you for cc 1554339471 March 22, 2002 EXIT OFF SCHULKYLL EXPRESSWAY LOWER MERION FRANCIS G KLENK JOHN KLENK ~ntinuing to work with Allstate Insurance Company on this underinsured motorist claim. Currently: 1. We are waiting for the completion of the court action We will inform you of the status of the claim until it is concluded. We anticipate that this matter will be resolved in 90 days or sooner. If you have any questions, feel free to contact us at 717-540-7500. ~- s~~~ Timothy Shaffer Allstate Insurance Company GKB 0208270005806180 ~ ~ f /" ~ , ' 000, , GEIC~ ^ Government Employees Insurance Compa ^ ~ ^ GEICO General Insurance Company ^ GEICO Indemnity Company . ^ GEICO Casualty Company One GEICO Blvd. ^ Fredericksburg, VA 22412-0001 August 22, 2002 JONATHAN MC GOVERN 2250 HICKORY RD STE 300 PLYMOUTH MEETING PA 19486 CLAIM NUMBER: 0114410410101 038 INSURED: Michael Hinchey DATE OF LOSS: 3/22/02 YOUR CLIENT: The Estate of Jahn F. Klenk ' Dear Mr. McGovern: Enclosed is a copy of the affidavit that I received from the attorney representing Michael Hinchey. If you have any additional questions or concerns, feel free to contact me at the number listed below. Sincerely, "0~ Tammy Rose Claims Ex e (540) 286-429 Enclosure dpw ~• Shareholder Owned Companies Not Affiliated With The U.S. Government .~~ AFFIDAVIT Come now, Michael Hinchey, who deposes and says the; following statements are true and correct as his knowledge and believe: 1. I am the registered owner and operator of a 1996 M<~zda Protege, which was involved in an accident on March 22, 2002; 2. At the time of the accident, my vehicle was insured by GEICO General Insurance Company under policy number 12773210; ..:. =.~:~ ~: _; `- i ``_~ 3. I have no other insurance to cover the 1996 Mazda Protege involved in this accident; nor do I qualify for insurance under any other automobile policy e~rc~++ ~tti,4~-' Qr~o{I,~r- in,uai.~~c~l rCS'~ wi-+t, Ma- ~..~4+0~ wa.5 ~- •~4.w~G.~ ;hs~.~tZ on ~ pott~c~. - ~~ (S tore in Full) _~ , ! y Zo 0 L (Date) Notary public: ~~L On this day of _, 20 ~ ~be;fore me personally appeared ~~~ ~ to me known to be the person named and who executed the above AfFidavit and acknowledged that `1 ~ exe,~uted the same as ~ ~ own free act and deed. i ~, Notary Publi NOTARIAL SEAL MARIAELENA PASTUSZEK Ndary Pub~bc City d p~adelptaa. Ph~a. Caxay My Cortx~ss~ Expires ~ ~~ 2006 My Commission Expires IN RE: JOHN KLENK, DECEASED IN THE COURT OF COMMON PLEAS ORPHANS' COURT DIVISION CUMBERLAND COUNTY, PENNSYLVANIA NO.21-2002-407 CITATION WE COMMAND, you that laying aside all business and excuses whatsoever, you be and appear in your proper person before the Honorable Judges of the Court of Common Pleas, Orphans' Court Division at a session of the said Court there to be held, for the County of Cumberland to show cause why THE COURT SHOULD NOT APPROVE THE SETTLEMENT AND DISTRIBUTION OF SETTLEMENT PROCEEDS IN ACCORDANCE WITH THE PROPOSED ORDER OF DISTRIBUTION CONTAINED IN THE PETITION. COPY OF PETITION TO BE SERVED WITH CITATION SERVICE TO BE EFFECTIED BY CERTIFIED MAIL RETURN RECEIPT REQUESTED ,UPON THOSE PERSONS IDENTIFIED ON THE ATTACHED LIST OF INTERSTED PARTIES. CITATION RETURNABLE THE 30~' DAY OF OCTOBER 2002 AT 1:30P.M. IN THE ORPHAN'S COURT DIVISION ROOM ,CUMBERLAND COUNTY COURT HOUSE CARLISLE, PENNSYLVANIA Witness my hand an official seal of office at Carlisle, Pennsylvania, this ~ ciay oi~~, 20~~ Clerk, Oipha 'Court Division Cumberland County, Carlisle, PA My Commission Expires on the ls` Monday January, b~ to AIN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHAN'S COURT DIVISION NO. OC-02-00407 ,ESTATE OF JOHN KLENK, DECEASED PETITION FOR CITATION TO AUTHORIZE SETTLEMENT OF WRONGFUL DEATH CLAIM PRELIMINARY DECREE AND NOW, this~~day of ~~~d ~.t, 2002 upon consideration of the annexed petition, a Citation is hereby awarded to all interested parties to show cause why the court should not approve the settlement and distribution of settlement proceeds in accordance with the proposed Order of distribution contained in the Petition. Copy of petition to be served with Citation. Service to be effected by certified mail, return receipt requested, upon those persons identified on the attached list of interested parties. Citation returnable the 3 ~ day of 2002, at / " 3 ~M. in the Orphan's Court Division Room ,Cumberland County Court House, Carlisle, Pennsylvania. BY THE COURT, J. ,, • ~. P~. ~~ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHAN'S COURT DIVISION NO. OC-02-00407 ESTATE OF JOHN KLENK, DECEASED O ER AND NOW, this day of ~ , 2002, upon consideration of the annexed petition, it is hereby ORDERED AND DECREED that Frank Klenk, as Executor of the estate of John Klenk, Deceased is authorized to enter into a settlement with Allstate Insurance Company for the gross proceeds of $500,00.00. Allstate is directed to forward all settlement drafts or checks to counsel for Petitioner for proper distribution. It is further ORDERED and DECREED that the settlement proceeds are allocated as follows: 1. To: O'Brien & Ryan, LLP (costs) $ 1,703.44 2. To: O'Brien & Ryan, LLP (counsel fees) $ 63,707.00 3. Wrongful Death Claim i. To: Frank Klenk, parent $ 217,294.78 ii. To: Mary Agnes Klenk, parent $ 217,294.78 4. Survival Claim i. To: Frank Klenk, Administrator of the Estate of John i~lenk, Deceased $ 0. B T, ~_ • J. .r IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHAN' S COURT DIVISION NO. OC-02-00407 ESTATE OF JOHN KLENK, DECEASED PETITION FOR CITATION TO AUTHORIZE THE SETTLEMENT OF WRONGFUL DEATH CLAIMS AND DISTRIBUTION OF SETTLEMENT PROCEEDS TO THE HONORABLE JUDGES OF SAID COURT: Petitioner, John Klenk, as parent and Executor of the estate of John Klenk, Deceased, through his attorneys, O'Brien & Ryan, LLP respectfully represents that: 1. The Decedent, John Klenk, age 20 died on March 22, 2002. The cause of death was multiple injuries to decedent, a pedestrian at the time, from being struck by a motor vehicle. 2. Decedent was never married, and died intestate, survived by his parents Frank and Mary Agnes Klenk (as well as three siblings). 3. Petitioner is Frank Klenk the decedent's father, who was appointed Administrator of the Estate of John Klenk, on Apri124, 2002 by the Register Of Wills of Cumberland County. (Decedent's mother, Mary Agnes Klenk rescinded her position to serve as administrator) A copy of the Decree of the Register is attached as Exhibit "A." 4. The parties-in-interest in this case are: A. Mary Agnes and Frank Klenk (petitioner herein) parents and intestate heirs of decedent residing at: 504 Partridge Court Mechanicsburg, PA 17050 B. Allstate Insurance Company Market Claim Office 6345 Flank Drive Harrisburg PA 17112 c/o Tim Shaffer, Claims 5. Petitioner, individually and as Administrator of the Estate of Decedent, gave notice to his insurance carrier, Allstate Insurance Company, of his intent to proceed with the institution of a wrongful death and survival action on behalf of himself ,his wife and the Estate with regard to the underlying tortious conduct which caused the death of the decedent John Klenk, but no separate action or summons has been filed as of this date. 6. Petitioner had contracted with Allstate Insurance company for the provision of Underinsured Motorist coverage under policy 1554339489-b27 and 1554339471-b27 in the total amount of $500,000.00 for any injuries sustained by the insured's covered individuals which included his son, John Klenk. 7. Allstate Insurance Company recently gave notice to counsel for Petitioner of its intent to tender the policy limits of its UIM policy upon the execution of a release of Petitioner and court approval of the settlement. 8. At the present time there is no other suit pending on behalf of the estate or Petitioner as counsel is still investigating various third party actions with regard to the damages sustained. In order not to delay the distribution of the above referenced policy proceeds, but to comply with Allstate's request to receive court approval, Petitioner brings the instant Petition and Citation. 9. The Tortfeasor driver has offered to tender his automobile policy limits of $15,000.00 in settlement of any potential third party case. 10. Petitioner has not accepted the settlement offer of the tortfeasor driver as Counsel is still investigating all potential actions and awaiting the outcome of tortfeasor's criminal charges associated with the death of decedent, including the pending charge of homicide by vehicle, while driving under the influence. 11. In accordance with Pa. C.S. 20 Section 3171, the grant of letters to Petitioner was advertised for three consecutive weeks, on August 15, 22 and 29, 2002. 12. Presently, there are no known unpaid claims raised or outstanding in the decedent's estate. 13. Counsel is of the opinion that there may be liens that would arise under the provisions of the health insurance contracts applicable to the decedent against any damages chazacterized as "survival" damages recoverable by the Estate for the costs involved in providing medical care to the decedent for the injuries that caused his death in the approximate amount of $43,067.00. No such lien will arise for wrongful death recovery by Petitioner. 14. Counsel is of the professional opinion that the proposed settlement of the claims for which Allstate Insurance underinsured coverage applies is reasonable due to the following: (a) The total policy limits for Underisured coverage have been offered, with the only requirement being court approval of the disbursement [see attached hereto as Exhibit "B" correspondence of Allstate Insurance company dated August 16 and 27, 2002; (b) Although court approval in not required for the settlement of the underinsured policy limits of Petitioner's Allstate policy, court approval is sought by the Insurer as a requirement of their release of the funds; (c) Upon investigation and belief to date, the tortfeasor driver's insurance coverage applicable to the damages that would be claimed in any wrongful death or survival action is the statutory minimum of $15,000.00. [see attached hereto as Exhibit "C" correspondence dated August 22, 2002 from Geico Direct, Insurer, and affidavit of the driver, Michael Hinchey. (d) Upon investigation and verbal confirmation by the tortfeasordrer's legal counsel, Mr. Hinchey has no personal assets upon which a wrongful death or survival judgment award would be recoverable. (e) There are no other identifiable sources of recovery at this time for petitioner as either parent or executor. 15. Petitioner is of the opinion that the proposed settlement is reasonable. 16. Allstate Insurance Company does not object to the distribution as proposed [100% allocatable to Wrongful Death damages] and seeks only execution of a general release to Allstate and court approval of the distribution. 17. Counsel has incurred a total of $1,073.44 in expenses for which reimbursement is sought. 18. Counsel requests counsel fees in the amount of $63,707.0(), which represents legal fees incurred between March 25, 2002 and September 25, 2002 based upon counsel's hourly fee agreement entered with John Klenk, Petitioner. 19. Petitioner requests allocation of the net proceeds of the settlement (after deduction of costs and attorneys fees) as follows: A. Wrongful Death Claim $ 434,589.57 B. Survival Claim $ 0. 20. The reason for the requested allocation in total to a wrongful death recovery distribution is as follows: Petitioner under a wrongful death action would be entitled to recover damages for hospital, nursing, medical, funeral expenses and expenses of administration necessitated by reason of injuries causing death, including the pecuniary loss of the decedent to decedent's family. The instant settlement seeks to compensate the parents for the losses they incurred in providing for the above expenses in and for the death of their 20 year old son, a healthy, promising college student. 21. Pursuant to the Wrongful Death Statute (42 Pa. C.S.S. 8301), and the Intestacy Act the beneficiaries of the Wrongful Death Claim and the proportion of theix interest , are as follows: Mary Agnes Klenk 50% Frank Klenk 50% 22. The damages incurred by the beneficiaries listed above includes the expenses for hospital, nursing, medical, funeral expenses, as well as the recoverable portions of the expenses incurred in the estate's administration. Petitioner as parent has also lost the maintenance, service, gifts and the expectations of future enjoyment of such maintenance services and gifts. 23. There is no impact on the tax Inheritance applicable to this Estate in apportioning the distribution as 100% allocatable to wrongful death as any distribution occurring in this Estate passes to the intestate heirs beneficiaries at a rate of "0." See 72 P.S. §9116 (a)(1.2). "inheritance tax upon the transfer of property, from child twenty-one (21) years of age or younger to or for the use of a natural parent, ... shall be at the rate of zero per cent. " WHEREFORE, petitioner prays that a Citation be issued to the persons listed above in paragraph 4 asparties-in-interest to show cause, if any there are, why the proposed citation should not be issued providing for the settlement of wrongful death claims under Allstate's policies and distribution as provided in the proposed Order of Distribution as follows: 1. To: O'Brien & Ryan, LLP (costs) $ 1,703.44 2. To: O'Brien & Ryan, LLP (counsel fees) $ 63,707.00 3. Wrongful Death Claim i. To: Frank Klenk, parent $ 217,294.57 ii. To: Mary Agnes Klenk, parent $ 217,294.57 4. Survival Claim i. To: Frank Klenk, Administrator of the Estate of John Klenk, Deceased $ 0. Respectfully submitted, O'Brien & Ryan, LI,P .... .. _._.~ Q~x mary R. rrino; Esquire Suite 300, Hi kory Pointe Plymouth Meeting, PA 19462 Attorney for Petitioner Register of Wills of CUMBERLAND County, Pennsylvania Certificate of Grant of Letters PA No. 21-02-0407 ESTATE OF KLENK JOHN F No. 2002-00407 Late of HAMPDEN TOWNSHIP , Deceased Social Security No. 181-62-6595 WHEREAS, KLENK JOHN F late of HAMPDEN TOWNSHIP --- CUMBERLAND COUNTY died on the 22nd day of and WHEREAS, the grant of letters of administration is required for the administration of the estate. March 2002; THEREFORE, I, MARY C. LEWIS Register of Wily in and for the County of CUMBERLAND in the Commonwealth of Pennsylvania, have this day granted Letters of Administration to KLENK FRANCIS ( , who has duly qualified as administrator(rix) of the estate of the above named decedent and has agreed to administer the estate according to law, all of which fully appears of record in my Office at CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNSYLVANIA. IN TESTIMONY WHEREOF, I have hereunto set my hand ,and affixed the seal of my Office on the 24th day of April 2002. C,' ~~R~~~cl egis r o i **NOTE** ALL NAMES ABOVE APPEAR (LAST, FIRST, MIDDLE) AUG. ?5. 2002 8:39AM ALLSTAIE INS. A~Istate Hbg, 1'a. 1 /l 11 MARKET CLAIM OFFICE 6345 FLANK DRIVE HARRIS6URG PA 17~ 12 ~, 7saoasss Fax 717-540.7540 EMAIL ed91p®allstate.eam August 16, 2002 Jonatfian C. McGovern, Esquire O'Brien & Ryan, [J.P 2250 Hickory Read, Suite 300 Plymouth Meeting, PA 19462-1047 Ref®rence: Your Client: Estate of John Klenk Our Claim Number: 1554339489-B27 and 1554339471-827 Dear Mr. McGovern: NU. 41 i r. Z ~~~~ ~ ~. ~tY~G This letter is to confirm our settlement offer of $500,000 between the two above captioned claim numbers. Enclosed please find the proposed UlM releases. Once this settlement has been court approved we will be in a position to release our settlement drafts. Lastly, Allstate will waive its subrogation versus Michael Hinchey and consent to the settlement with his carrier Geico Insurance- We do consent to a general release. As always, thank you for your attention to this matter. Sincerely, T" ._ . ~~ Tim Shaffer, SCLA Staff Claim Reprasentativo ALLSTATElNSURANCE COMPANY ~ `~ ~ ~' ~~~~! MARKET CLAIM OFFICE You re ~ good hand' 6345 FLANK DRIVE SUITE 1000 HARRISBURG PA 17112-2765 ~u~~~~~~n~~n~~~~nu~~~u~~~~~n~~~n~~u~~~n~~~~~~n~~~~~ JONATHAN MCGOVERN 2250 HICKORY RD. STE 300 PYLMOUTH MEETING PA 19462-1047 Loss Report Date: March 22, 2002 2002 August 27 , Claim Number: 1554339489 Date of Loss: March 22, 2002 Location: PHILA Our Insured: FRANCIS G KLENK Claimant: JOHN KLENK S/B 1554339471 Thank you for continuin g to work with Allstate Insurance Company on this underinsured motorist claim. Currently: 1. We are waiting for the completion of the court action We will inform you of the status of the claim until it is concluded. We anticipate that this matter will be resolved in 90 days or sooner. If you have any questions, feel &ee to contact us at 717-540-7500. ~u~~~~y s~a;~~ Timothy Shaffer Allstate Insurance Company GKB 0208270005906180 ,r* ~' _ _ . :~ ALLSTATE LNSI/RANCE COMPANY `` • ~'' ! ~~ ~ MARKET CLAIMOFFICE YouYe in good ha 6345 FLANKDRIYE SUITE 1000 HARRISBURG PA 17112-2765 ~ui~~~~~n~~n~~~~~n~~~~n~~~~~uu~u~~u~~~ni~~~~~u~u~~ JONATHAN MCGOVERN 2250 HICKORY RD. STE 300 PYLMOUTH MEETING PA 19462-1047 August 27, 2002 Loss Report Date: March 22, 2002 Claim Number: 1554339471 Date of Loss: March 22, 2002 Location: EXIT OFF SCHULKYLL EXPRESSWAY LOWER MERION Our Insured: FRANCIS G KLENK Claimant: JOHN KLENK Thank you for continuing to work with Allstate Insurance Company on this underinsured motorist claim. Currently: 1. We are waiting for the completion of the court action We will inform you of the status of the claim until it is concluded. We anticipate that this matter will be resolved in 90 days or sooner. If you have any questions, feel free to contact us at 717-540-7500. ~~ s~~~ Timothy Shaffer Allstate Insurance Company GKB 0208270005806180 '~ GEICO ~ ~. ,v~~ ~ : ~ ~ ~~ ® ^ Government Employees Insurance Company ^ ~ ^ GEICO General Insurance Company ' ^ GEICO Indemnity Company (\\~..' ^ GEICO Casualty Company One GEICO Blvd. ^ Fredericksburg, VA 22412-0001 August 22, 2002 JONATHAN MC GOVERN 2250 HICKORY RD STE 300 PLYMOUTH MEETING PA 19486 CLAIM NUMBER: 011441041 0101 038 INSURED: Michael Hinchey DATE OF LOSS: 3/22/02 YOUR CLIENT: The Estate of John F. Klenk Dear Mr. McGovern: Enclosed is a copy of the affidavit that I received from the attorney representing Michael Hinchey. If you have any additional questions or concerns, feel free to contact me at the number listed below. Sincerely, 1 ~ Tammy Rose Claims Ex e (540) 286-429 Enclosure dpw ~. Shareholder Owned Companies Not Affiliated With The U.S. Government "} . • AFFIDAVIT Come now, Michael Hinchey, who deposes and says the. following statements are true and correct as his knowledge and believe: - ~ 1. I am the registered owner and operator of a 1996 Mazda Protege, which was involved in an accident on March 22, 2002; 2. At the time of the accident, my vehicle was insured by GEICO General Insurance Company under policy number 12773210; 3. I have no other insurance to cover the 1996 Mazda Protege involved in this accident; nor do I qualify for insurance under any other automobile policy, e~tc~e~~ -t~c~- gho{t,~r inc!soi~(vicel reS'd~ wi-+H ~ c.~4w was a. r~c..wtll~+ i ins~~GZ on ~. pa lrc~. 7/ G (S tore in Full) _ ~~, ! y Zoo z., (Date) Notary public: ~~L On this day of , 20 ~ before me rersonally arpcard ~j ~ ,/~1 ~~ ~~ ~ n ~ ~ to me known to be the person named and who executed the above Affidavit and acknowledged that 67~ ____ executed the same as ~ ~ own free act and deed. >..~ ~a ~. ~ Notary Publi NOTARIAL SFAL - . ~ MARfA~LENA PASTUSZEK Notary Public City of Philadelphia, Phhil~a. Cau~ty My C,ortxr~on Expires April 23, 2006 My Commission Expires ~' BRIAN & RYAN, LLP ATTORNEYS AT LAW Hickory Pointe 2250 Hickory Road, Suite 300 Plymouth Meeting, PA i 94G2-7047 Main: C670) 8348800 Fax: (610) 8341 T49 www.obrlaw.com Rosemary R Ferrino Direct Dial: (610) 834-6270 Email: rfeiTino(k;obrlaw.com October 24, 2002 Orphans Court Cumberland County Courthouse 1 Courthouse Square Carlisle, PA 17013 Attention :Donna M. Otto RE: Estate of John F. Klenk Our File No. 91612 OC-0200407 Dear Ms. Otto: Pursuant to the telephone we have had, you will note that I represent the Estate of John Klenk in the above stated matter. Presently before the Court is a Petition for Citation to Authorize Settlement of a Wrongful Death Claim. Service, pursuant to the Citation of October 3rd on all interested parties has occurred, and I am herewith enclosing for filing an Affidavit of Service which incorporates written confirmation that there is no objection to the proposed Order contained in the Petition. However, as discussed, I have also enclosed herein an Amended Petition to authorize the identical settlement. The amendments contained therein are limited to correcting typographical errors in the original petition and do not alter the substantive content of the original petition or the proposed order. The amendments are to address and clarify any confusion that might occur in that the names of the decedent and his administrator were inadvertently transposed in a portion of the original pleading, and to utilize the formal name of the administrator to conform to the grant of letters to him. A filing fee is enclosed for same. You indicated that you might benefit by having a copy of the full original Petition to attach to the Amended Petition if necessary, and therefore, a copy of the original Petition, filed on October 3, 2002 is enclosed. A Rule Returnable hearing is scheduled on October 30, 2002, before the Honorable George E. Hoffer. I have confirmed that I will attend that hearing and submit an additional Affidavit of Service that the Amended Petition was served upon the same interested parties and that the amendments do not change their position, and that they continue to support the proposed Order. Thank you for your assistance in addressing my concerns about the original Petition and in seeing to it that these filings do not delay forwarding the file to Judge Hoffer prior to October 30, 2002. _. Very truly yoxi~s, jr .. ,~ l~»~R~ R. FERRINO RRF/j lm Enclosure cc: Tim Shaffer, (via facsimile and regular mail) IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHAN'S COURT DIVISION NO.OC-02-00407 ESTATE OF JOHN KLENK, DECEASED ORDER ~~~ AND NOW, this ~S a of , 2002, upon consideration of the annexed - Amended Petition, it is hereby ORDERED AND DECREED that Francis G. Klenk, as Administrator of the Estate of John Klenk, Deceased is authorized to enter into a settlement with Allstate Insurance Company for the gross proceeds of $500,000.00. Allstate is directed to forward all settlement drafts or checks to counsel for Petitioner for proper distribution. It is further ORDERED and DECREED that the settlement proceeds are allocated as follows: 1. To: O'Brien & Ryan, LLP (costs) $ 1,703.44 2. To: O'Brien & Ryan, LLP (counsel fees) $ 63,707.00 3. Wrongful Death Claim i. To: Francis G. Klenk, parent $ 217,294.78 ii. To: Mary Agnes Klenk, parent $ 217,294.78 4. Survival Claim i. To: Francis G. Klenk, Administrator of the Estate of John Klenk, Deceased $ 0. i IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHAN'S COURT DIVISION NO.OC-02-00407 ESTATE OF JOHN KLENK, DECEASED AMENDED PETITION FOR CITATION TO AUTHORIZE THE SETTLEMENT OF WRONGFUL DEATH CLAIMS AND DISTRIBUTION OF SETTLEMENT PROCEEDS TO THE HONORABLE JUDGES OF SAID COURT: Petitioner, Francis G. Klenk, as parent and Administrator of the Estate of John Klenk, Deceased, through his attorneys, O'Brien & Ryan, LLP respectfully represents that he filed, on October 3, 2002, a Petition to Authorize Settlement identical to the averments listed in paragraphs one (1) through twenty-three (23) below and seeks to amend only said Petition at this time to address typographical errors contained in the original Petition. 1. The Decedent, John Klenk, age 20, died on March 22, 2002. The cause of death was multiple injuries to decedent, a pedestrian at the time, from being struck by a motor vehicle. 2. Decedent was never married, died intestate, and is survived by his parents Francis G. and Mary Agnes Klenk (as well as three siblings). 3. Petitioner is Francis G. Klenk, the decedent's father, who was appointed Administrator of the Estate of John Klenk, on Apri124, 2002 by the Register of Wills of Cumberland County. Decedent's mother, Mary Agnes Klenk rescinded her position to serve as administrator. A copy of the Decree of the Register is attached to the original Petition as Exhibit "A." 4. The parties-in-interest in this case are: A. Mary Agnes and Francis G. Klenk (petitioner herein) parents and intestate heirs of decedent residing at: 504 Partridge Court Mechanicsburg, PA 17050 B. Allstate Insurance Company Market Claim Office 6345 Flank Drive Harrisburg PA 17112 c/o Tim Shaffer, Claims 5. Petitioner, individually and as Administrator of the Estate of Decedent, gave notice to his insurance carrier, Allstate Insurance Company, of his intent to proceed with the institution of a Wrongful Death and Survival Action on behalf of himself, his wife and the Estate with regard to the underlying tortious conduct which caused the death of the decedent John Klenk, but no separate action or summons has been filed as of this date. 6. Petitioner had contracted with Allstate Insurance Company for the provision of Underinsured Motorist Coverage under policy 1554339489-b27 and 1554339471-b27 in the total amount of $500,000.00 for any injuries sustained by the insured's covered individuals which included his son, John Klenk. 7. Allstate Insurance Company recently gave notice to counsel for Petitioner of its intent to tender the policy limits of its UIM policy upon the execution of a release of Petitioner and court approval of the settlement. 8. At the present time there is no other suit pending on behalf of the Estate or Petitioner as counsel is still investigating various third party actions with regard to the damages sustained. In order not to delay the distribution of the above referenced policy proceeds, but to comply with Allstate's request to receive court approval, Petitioner brings the instant Amended Petition and Citation. 9. The tortfeasor driver has offered to tender his automobile policy limits of $15,000.00 in settlement of any potential third party case. 10. Petitioner has not accepted the settlement offer of the tortfeasor driver as counsel is still investigating all potential actions and awaiting the outcome of tortfeasor's criminal charges associated with the death of decedent, including the pending charge of Homicide by Vehicle, While Driving Under the Influence. 11. In accordance with 20 Pa. C.S. Section 3171, the grant of letters to Petitioner was advertised for three consecutive weeks, on August 15, 22 and 29, 2002. 12. Presently, there are no known unpaid claims raised or outstanding in the decedent's estate. 13. Counsel is of the opinion that there may be liens that would arise under the provisions of the health insurance contracts applicable to the decedent against any damages characterized as "survival" damages recoverable by the Estate for the costs involved in providing medical care to the decedent for the injuries that caused his death in the approximate amount of $43,067.00. No such lien will arise for wrongful death recovery by Petitioner. 14. Counsel is of the professional opinion that the proposed settlement of the claims for which Allstate Insurance underinsured coverage applies is reasonable due to the following: (a) The total policy limits for underinsured coverage have been offered, with the only requirement being court approval of the disbursement (see attached to the original Petition as Exhibit "B", correspondence of Allstate Insurance Company dated August 16 and 27, 2002); (b) Although court approval is not required for the settlement of the underinsured policy limits of Petitioner's Allstate policy, court approval is sought by the Insurer as a requirement of their release of the funds; (c) Upon investigation and belief to date, the tortfeasor driver's insurance coverage applicable to the damages that would be claimed in any wrongful death or survival action is the statutory minimum of $15,000.00. (See attached to the original Petition as Exhibit "C" correspondence dated August 22, 2002 from Geico Direct, Insurer, and affidavit of the driver, Michael Hinchey.) (d) Upon investigation and verbal confirmation by the tortfeasor's legal counsel, Mr. Hinchey has no personal assets upon which a wrongful death or survival judgment award would be recoverable. (e) There are no other identifiable sources of recovery at this time for petitioner as either parent or executor. 15. Petitioner is of the opinion that the proposed settlement is reasonable. 16. Allstate Insurance Company does not object to the distribution as proposed (100% allocatable to wrongful death damages) and seeks only execution of a general release to Allstate and court approval of the distribution. 17. Counsel has incurred a total of $1,073.44 in expenses for which reimbursement is sought. 18. Counsel requests counsel fees in the amount of $63,707.00, which represents legal fees incurred between March 25, 2002 and September 25, 2002 based upon Counsel's hourly fee agreement entered into with Francis G. Klenk, Petitioner. 19. Petitioner requests allocation of the net proceeds of the settlement (after deduction of costs and attorneys fees) as follows: A. Wrongful Death Claim $ 434,589.56 B. Survival Claim $ 0. 20. The reason for the requested allocation in total to a wrongful death recovery distribution is as follows: Petitioner under a wrongful death action would be entitled to recover damages for hospital, nursing, medical, funeral expenses and expenses of administration necessitated by reason of injuries causing death, including the pecuniary loss of the decedent to decedent's family. The instant settlement seeks to compensate the parents for the losses they incurred in providing for the above expenses in and for the death of their 20 year old son, a healthy, promising college student. 21. Pursuant to the Wrongful Death Statute (42 Pa. C.S.§ 8301), and the Intestacy Act the beneficiaries of the wrongful death claim and the proportion of their interest are as follows: Mary Agnes Klenk 50% Francis G. Klenk 50% 22. The damages incurred by the beneficiaries listed above includes the expenses for, hospital, nursing, medical, funeral expenses, as well as the recoverable portions of the expenses incurred in the Estate's administration. Petitioner, as parent, has also lost the maintenance, service, gifts and the expectations of future enjoyment of such maintenance, services and gifts. 23. There is no impact on the inheritance tax applicable to this Estate in apportioning the distribution as 100% allocatable to wrongful death as any distribution occurring in this Estate passes to the intestate heirs/beneficiaries at a rate of "0." See 72 P.S. §9116 (a)(1.2). WHEREFORE, petitioner prays that a Citation be issued to the persons listed above in paragraph four (4) as parties-in-interest to show cause, if any there are, why the proposed citation should not be issued providing for the settlement of wrongful death claims under Allstate's policies and distribution as provided in the proposed Order of Distribution as follows: 1. To: O'Brien & Ryan, LLP (costs) $ 1,703.44 2. To: O'Brien & Ryan, LLP (counsel fees) $ 63,707.00 3. Wrongful Death Claim i. To: Francis G. Klenk, parent $ 217,294.78 ii. To: Mary Agnes Klenk, parent $ 217,294.78 4. Survival Claim i. To: Francis G. Klenk, Administrator of the Estate of John Klenk, Deceased $ 0. Respectfully submitted, O'Brien & Ryan, LLP -~ ~~ G~` ~.~-~ O ARY . FERRINO, ESQUIRE Suite 300, Hickory Pointe Plymouth Meeting, PA 19462 Attorney for Petitioner ~ IN THE COURT OF COMMON PLEAS ~ OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHAN'S COURT DIVISION NO. OC-02-00407 ESTATE OF JOHN KLENK, DECEASED AFFIDAVIT OF SERVICE I, Rosemary R. Ferrino, Esquire, do hereby certify that I caused a true and correct copy of Petitioner, Francis Klenk's Petition to Authorize Settlement of Wrongful Death Claim to be served via hand delivery and and by first class United States mail on October 4, 2002 to the following interested parties: Francis G. Klenk and Mary Agnes Klenk h/w 504 Partridge Court Mechanicsburg, PA 17050 I, Rosemary R. Ferrino, Esquire, do hereby certify that I caused a true and correct copy of Petitioner, Francis Klenk's Petition to Authorize Settlement of Wrongful Death Claim to be served via certified/return receipt requested, and by first class United States mail on Tim Shaffer, SCLA on October 9, 2002 to the following interested party. Tim Shaffer, Claims Allstate Insurance Company Market Claim Office 6345 Flank Drive Harrisburg, PA 17112 I further represent that all interested parties have no objection to the Proposed Order contained in the Petition, and in support thereof, is correspondence of Allstate Insurance Company, dated October 11, 2002, wherein this position is set forth as attached. Respectfully submitted, O'Brien & Roman, LLP _ ~ P ~ ...~ Iosemary R. F rri o,^Esqu~/i//r/e~,/~/( Attorney for Petitioner Allstate Rosemary Perrino, Esquire O'Brien & Ryan, LLP 2250 Hickory Road, Suite 300 Plymouth Meeting, PA 19462-1047 MARKET CLAIM OFFICE 6345 FLANK DRIVE HARRISBURG PA 17112 717-540-7555 '~ Fax 717-540-7540 EMAIL cdgjp~allstate.com October 11, 2002 Reference: Your Client: Estate of John Klenk Our Claim Number: 1554339489-627 Dear Mr. Perrino: Thank you for forwarding the proposed petition. Upon review, we do not have any objections to the to the Petition. As always, thank you for your cooperation with this matter. Sincerely, ~_ Tim Shaffer, SCLA Staff Claim Representative R~_,~~~m> COMMONWEALTH OF REV -15 0 0 PENNSYLVANIA _ ~ ~ tj 9 - ~~ DEPARTMENT OF REVENUE INHERITANCE TAX RETURN _ FILE NUMBER ~- ~•~~ ~ ~~~-~~~~ ~~~- DEPT.280601 _ 02 00407 HARRISBURG, PA 17128-0601 RESIDENT DECEDENT C~TY ODE YEAR -NUMBER - - DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER ~"' Z Klenk, John F. 1$1-62-6595 W DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DUPLICATE WITH THE U 03/22/02 11/06/81 REGISTER OF WILLS W (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER ~ Not applicable F ~ 1.Original Retum ^ 2. Supplemental Retum ^ 3. Remainder Retum (date or death prior to lz•79AZ> ~ ~ x ^ 4. Limited Estate ^ 4a. Future Interest Compromise (dale oreea,h aner ~z-is-szl ^ 5. Federal Estate Tax Retum Required ~ ~ m ^ 6. Decedent Died Testate taua, ivy arwiiQ ^ 7. Decedent Maintained a Living Trust (Attach cosy orrnut) 8. Total Number of Safe Deposit Boxes a a ^ 9. Litigation Proceeds Received _ ^ 10. Spousal Poverty Credit (ease or dean, belweao ~2-3~ai and ~-i-ssl ^ 11. Election to tax under Sec. 9113(A) (Much scn of F THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD.BE'DIRECTED TO: z w NAME COMPLETE MAILING ADDRESS o c/o Rosemary R. Perrino, Esquire 2250 Hickory Road Suite 300 a FIRM NAME InAaviwaael ' , Hickory Pointe Brien & Ryan, LLP. O Pl mouth Meetin PA 19462 o TELEPHONE NUMBER y g, ~ (610) 834-8800 Z 0 Q J N a Q V W 11. Total Deductions (total Lines 9 & 10) (11) 65,410.00 12. Net Value of Estate (Line 8 minus Une 11) (12) 449,678.50 13. Charitable and Governmental BequestslSec 9113 Trusts for which an election to tax has not been (13) made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) 449,678.50 1. Real Estate (Schedule A) (1) 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 4. Mortgages 8 Notes Receivable (Schedule D) (4) 5. Cash, Bank Deposits 8 Miscellaneous Personal Property (5) 515,000.00 = (Schedule E) 6. Jointly Owned Property (Schedule F) (6) 88.50 ^ Separate Billing Requested 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (7) (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) (8) 515,088.00 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 65,410.00 10. Debts of Decedent, Mortgage Liabilities, b Liens (Schedule I) (10) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES Z ~ 15. Amount of Line 14 taxable at the spousal tax 449 678 50 0 00 i-- H , . rate, or transfers under Sec. 9116 (a)(1.2) 16. Amount of Une 14 taxable at lineal rate x .0 _ x .0 _ . (15) - (16) - ~" 17. Amount of Une 14 taxable at sibling rate x .12 {17) _ V 18. Amount of Line 14 taxable at collateral rate x .15 {18) 19. Tax Due (19) - 0.00 1~:!tr- ~~,,.,~~,.~``'.+'.>'BE$URE~TO`ANSWER74Lx.^C~UESTIONSON ~ _ D D.'RECHECIC~AAATFi<:<'";>x`'~4~,'M;~'~ a~,';,"~~'rlii~,+~ti,~, Decedent's Complete Address: STREET ADDRESS 504 Partridge Court clTVMechanicsburg STATEPA ZIP 17050 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. Interest/Penalty if applicable D. I nterest E. Penalty (1) Total Credits (A + B + C) (2) Total Interest/Penalty (D + E ) 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 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. (3) (4) (5) (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) Make Check Payable fo: 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 :.......................................................................................... ^ ^Q b. retain the right to designate who shall use the property transferred or its income : ............................................ ^ ^Q c. retain a reversionary interest; or .......................................................................................................................... ^ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ^ 0 3. Did decedent own an "intrust for" or payable upon death bank account or security at his or her death? .............. ^ ^Q 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ........................................................................................................................ ^ ^X 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 true, correct and complete. DedaraGon of preparer other tl~an the personal representative is based on all information of which preparer has any knowledge. SIGNATURE 65PERSON RESPONSIBLE FOR.FIUNG R DATE / G~ 504 Partridge Court, Mechanicsburg, PA 50 _ SIG F PREPARER OTH ENTAT DA E O'Brien & Ryan, L ., 2250 Hickory Road, Suite 300, Hickory Pointe, Plymouth Meeting, PA 19462 For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not 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, or a stepparent of the child is 0% [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF John F. Klenk, deceased SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER 02-00407 Indude the proceeds of litigation and the date the proceeds were received by the estate. All property Jointlyowned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Wrongful death recovery approved by Judge Hoffer of the Orphan's Court of 500,000.00 Cumberland County made payable to the parents of decedent as per the attached Ordered dated October 25, 2002 2 See correspondence dated December 11, 2002 to which J. Paul Dibert responded, acknowledging potential recovery of tortfeasor's auto policy limits of $15,000.00 and the potential to place same against survival damages recoverable by the estate. TOTAL (Also enter on line 5, Recapitulation) b (If more space is needed, insert additanal sheets of the same size) 15, 000.00 515,000.00 ~fi l(~t~ ~ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHAN'S COURT DIVISION NO.OC-02-00407 ESTATE OF JOHN KLENK, DECEASED {~ ORDER l-lm c~e_ AND NOW, this ~~ day of .~' , 2002, upon consideration of the annexed - Amended Petition, it is hereby ORDERED AND DECREED that Francis G. Klenk, as Administrator of the Estate of John Klenk, Deceased is authorized to enter into a settlement with Allstate Insurance Company for the gross proceeds of $500,000.00. Allstate is directed to forward all settlement drafts or checks to counsel for Petitioner for proper distribution. It is further ORDERED and.DECREED that the settlement proceeds are allocated as follows: 1. To: O'Brien & Ryan, LLP (costs) $ 1,703.44 2. To: O'Brien & Ryan, LLP (counsel fees) $ 63,707.00 3. Wrongful Death Claim i. To: Francis G. Klenk, parent $ 217,294.78 ii. To: Mary Agnes Klenk, parent $ 217,294.78 4. Survival Claim i. To: Francis G. Klenk, Administrator of the Estate of John Klenk, Deceased $ 0. BY THE COURT, -r~. ~.~ ~~ ; ,1 _ _ ~, i . _ O ~.^ r a a O' BRIEN & RYAN, LLP ATTORNEI(5 AT LAW wiry Pointe 2250 lilclcory Road, Suite 300 ply~rtouttt-Meetln9, PA 19462-1047 Male: <610) 834-8800 Fax: (610) 834-1749 www obtiaw com Rosemary R Ferrino Direct Dial: (610) 834-6270 Email: rferrino(uiobrlaw•.com December 11, 2002 J. Paul Dibert Pennsylvania Department of Revenue Bureau of Individual Taxes Harrisburg, PA RE: Estate of John F. Klenk, Deceased Date of Death: March 22, 2002 Social Security Number 181-62-6595 Our File No: 91612 -Dear Mr. Dibert: Pursuant to instructions received from Mr. Herr of your office, I enclose herein the pertinent details with regard to an inquiry on the necessity and correct reportability under REV - 1500 with regard to the above referenced Pennsylvania resident decedent, John F. Klenk. The deceased was twenty (20) years of age at the time of death on March 22, 2002; his date of birth is November 6, 1981. The cause of death was multiple injuries to the decedent, a pedestrian at the time, from being struck by a motor vehicle. The driver of the motor vehicle is currently facing criminal charges associated with the death of decedent including a charge of homicide by vehicle while driving under the influence. Decedent was never married, died intestate and is survived by his parents, Francis G. and Mary Agnes Klenk (as well as three (3) siblings.) Francis G. Klenk was appointed Administrator of the Estate of John F. Klenk on April 24, 2002 by the Register of Wills, Cumberland County under Administration Number 2002- 00407. Decedent's mother, rescinded her position to serve as Administrator of the Estate. The decedent was afull-time college student at the time of his death. The decedent held no assets in his name individually at the time of his passing, but did own a joint bank account with his mother with a date of death balance of $177.00 The decedent's parents have received a total of $434,589.56 in compensation for wrongful death injuries pursuant to two (2) Allstate Insurance Company policies owned by them providing for proceeds for under insured motorist coverage. Said distribution as wrongful death damages received Court approval on October 25, 2002. Enclosed herein is an Order dated 10/25/02 approving of said distribution. At present, there is no other suit pending on behalf of the estate for the damages sustained by the decedent or his estate. The tortfeasor driver has offered to tender his automobile policy limits of $15,000.00 in settlement of any potential third party case but said limits have not been accepted by the Administrator of the Estate while all potential actions await the outcome of the tortfeasor's criminal charges associated with the death of decedent. While additional damage amounts may be recovered and available to the estate, none are in the possession of the Administrator at this time. The PA-1500 is due for filing by December 22, 2002. It is likely that the any additional recovery, even if deemed "survival damages" to the estate [for costs involved in providing medical care to the decedent for treatment of injuries] will likely face a lien from the medical insurance company provider in the approximate amount of $43,067.00 as this is the figure reflected in the medical bills I was able to secure for the treatment provided. It is my understanding that a Pennsylvania Inheritance Tax Return indicating that all inheritance tax applicable to this estate whether assets are for recovery for wrongful death or survival damages passes to the intestate heirs [the parents] at a rate of zero as per 72 PA. § 9116 (a) (1.2). We are requesting input on where/ how to properly reflect this on the schedules. Your input with regard to our position would be greatly appreciated. Res ully su i tted, . ~---~ '~ ,G, ROSEMARY R. FERRINO RRF/jdl Enclosure Sent via fax 1-717-783-3467 . REV-1509 EX+ (6-98) SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER John F. Klenk, deceased 02-00407 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. Mary Agnes Klenk B. C. JOINTLY-OWNED PROPERTY: 504 Partridge Court, Mechanicsburg, PA 17055 ~ Parent ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCNL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYWG NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF OECD'S INTEREST DATE OF DEATH VALUE OF DECEDENTS INTEREST ~. A. 1999 Commerce Bank checking account 177.00 50 88.50 Account No.: 0430060884 TOTAL (Also enter on line 6, Recapitulation) I S 88.50 (If more space is needed, insert additional sheets of the same size) •. •REV-1511 EX+ (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES 8~ ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER John F. Klenk, deceased 02-00407 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. B. 1 2. 3. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Sodal Security Number(s)/EIN Number of Personal Representative(s) Street Address City State Year(s) Commission Paid: Attorney Fees Family Exemption: (If decedent's address is not the same as daimant's, attach explanation) Claimant Street Address City State _ Relationship of Claimant to Decedent Probate Fees Accountant's Fees Tax Return Preparer's Fees Legal costs (induding probate fees) Zip Zip 63,707.00 1,703.44 TOTAL (Also enter on line 9, Recapitulation) I s 65,410.44 (If more space is needed, insert additional sheets of the same size) REV-1513 EX+ (9-00) SCHEDULE J COMMONWEALTH of PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER John F. Klenk, deceased 02-00407 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not Llst Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [indude outright spousal distributions, and Uansfers under Sec. 9116 (a) (1.2)] 1 Francis G. Klenk Father 50% 2 Mary Agnes Klenk Mother 50% ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THRO UGH 18, AS APPROPRIATE, ON RE V-1500 COVER SHEET [[ NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET S (If more space is needed, insert additional sheets of the same size) i~-~9-~ BUREAU OF INDIVIDUAL TAXES INHERITANCE 7AX DIVISION DEPT. 280601 HARRISBURG, PA 17128-Ofi01 ROSEMARY R FERRINO ESQ OBRIEN & RYAN 2250 HICKORY RD 300. PLYMOUTH MTG PA 19462 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX REY-1547 E% ~FP (O1-OS7 DATE 02-25-2003 ESTATE OF KLENK JOHN F DATE OF DEATH 03-22-2002 FILE NUMBER 21 02-0407 COUNTY CUMBERLAND ACN 101 Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR RECORDS -~ ---------------------------------------------------------------------------------------------------------------- REV-1547 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF KLENK JOHN F FILE N0. 21 02-0407 ACN 101 DATE OZ-25-2003 TAX RETURN WAS: (X) ACCEPTED AS FILED ( ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate [Schedule A) (1) .00 NOTE: To insure proper 2. Stocks and Bonds (Schedule B) (2) .00 credit to your account, 3. Closely Held Stock/Partnership Interest (Schedule C) (3) .00 subwft the upper portion 4. Mortgages/Notes Receivable (Schedule D) (4) .00 of this fore with your 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) 515,00 0.0 0 tax payment. 6. Jointly Owned Property (Schedule F) (6) 88.50 7. Transfers (Schedule G) (7) .00 8. Total Assets (g) 515, 088.00 APPROVED DEDUCTIONS AND EXEMPTIONS: 65,410,00 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9) 10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) .00 11. Totai Deductions (11) 65.410.00 12. Net Value of Tax Return [12) 449,678.50 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) [13) .00 14. Net Value of Estate Subject to Tax [14) 449,678.50 NOTE: if an assessment was issued previously, lines 14, 15 andior ib, 17, 18 and 19 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate (15) 449,678.50 X 00 _ .00 16. Amount of Line 14 taxable at Lineal/Class A rate [16) •00 X 04 5 . .00 17. Amount of Line 14 at Sibling rate (17) .00 X 1 2 .00 18. Amount of Line 14 taxable at Collateral/Class B rate (18) •00 X 1 5 - .00 19. Principal Tax Due (19). .00 DATE AMOUNT PAID NUMBER INTEREST/PEN PAID [-l TOTAL TAX CREDIT .00 BALANCE OF TAX DUE ,00 INTEREST AND PEN. .00 TOTAL DUE .00 ^ IF PAID AFTER DATE INDICATED, SEE REVERSE ( IF TOTAL DUE IS LESS THAN S1, NO PAYMENT IS REQUIRED. FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT'' (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FDRM FOR INSTRUCTIONS.) Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 2/02/2005 FERRINO ROSEMAY 2250 HICKORY ROAD SUITE 300 PLYMOUTH MEETING, PA 19462 RE: Estate of KLENK JOHN F File Number: 2002-00407 Dear Sir/Madam: It has come to my attention that you have not filed the Status Report by Personal Representative (Rule 6.12) 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 two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing will become delinquent on: 3/22/2005 Your prompt attention to this matter will be appreciated. Thank You. Sincerely, f~~.. GLENDA FARMER STRASBAUGH REGISTER OF WILLS cc: File Personal Representative(s) Judge 4.~ 044/13/2005 11:12 FAX 6108341749 OBRIEN & RYAN LLP 1003/003 1'. VU]I uU~ F. '• ;a05{NON) 10:57 SIEMENS pLpfi TECHNOLOGIES HB6 BR tFRX)flf bar drys a~Wd1s ~laad Conaip _~_ T Nam e~ne~d~ o~n/ f Kl~N DareofDe~ I'nl~N ZZ ?vD Z F~ Na: '7:o p 2 ~ 00 ~o ~- ~. Puuraus>se to Rule 6. iz o~F the Sumo Court pcplxnas' couss Rules. I report ~ ienowimc w~ r w completi~oa of tho ~ of the abcrvaa-ptionod es>~ ~ . 3t~oDC wbe~ a~oa of clte is otympld+c: ' y~ ~[ No Z If the answer is Ne, 5mm ahm the pcrsotusl rppvc rp~opably bdiaves that the soon wt~l.be compk~ DEf ~~-'' 131~'~' 2 ny 3_ Iftbe aaSwCr >n No. l is Xa, state the foIIovvln~ a Did srio p~soaal p~~vo file a Seal account with the Court? Yes ~ No b. Tba Ctpl~a' Court No. ('f any) far the personal ~G~e aco4u~ti~ c. Did the panonai ~eprrseutative state a:t acwvat iuformalty m the patties in ? Yeo n No ~ ~ ' Copies of receipt4 rdeas~ jaindeoc6 and appiaval of fetmal or ia$omoal aeeeunts mny be 51ed with Tyr Clede erFthe Ocp1'~an5' C~~ ~d ~' be at#aehed tin tbas repaes. ~ f~ - ~ . Da~2 (L v Name ST'E 3o a Z~~v H~c+rv ~y ~ PC.vv~io~YH ~~ pA r~~/~ Z ~~~ g ~y~ 4298 Te1Cp>tona No. i~ p~o~ Represeat~ive Cauusel for pacsangl Yep~t~Gpva Estate of KLENK JOHN F Late of HAMPDEN TOWNSHIP Estate No.: 21-02-00407 Date: 4/08/2005 FERRINO ROSEMAY 2250 HICKORY ROAD SUITE 300 PLYMOUTH MEETING PA 19462 ORPHANS' COURT DIVISION COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA NO.: 21-02-00407 NOTICE OF FAILURE TO FILE STATUS REPORT AND REQUEST TO CONDUCT A HEARING PURSUANT TO RULE 6.12, SUPREME COURT ORPHANS' COURT RULE Personal Representative: KLENK FRANCIS Personal Representative Counsel: FERRINO ROSEMAY Date of Decedent's Death: 3/31/2002 Date of Delinquency Notice: 3/22/2005 The undersigned, Glenda Farner Strasbaugh, Clerk of Orhans' Court, in accordance with rule 6.12, Supreme Court Orphans' Court Rules, hereby notifies the Orphans' Court Division, Court of Common Pleas of Cumberland County, that neither the above named personal representative nor their counsel, have filed with the Register of Wills or Clerk of Orphans' Court, his/her Status Report required by Rule 6.12, Supreme Court Orphans' Court Rule, and that the requisite notice, pursuant to Rule 6.12, Supreme Court Orhans' Court Rules, was given by the Clerk of Orphans' Court on 3/03/2005 and that the ten (10) day notice to file the status report has expired. Accordingly, in accordance with Rule 6.12 the Court is hereby notified of such delinquency and the undersigned requests that a Court conduct a hearing to determine whether sanctions should be imposed upon the delinquent personal representative or their counsel. cc: File Personal Representative Glenda Farner Strasbaugh Counsel Clerk of Orhans' Court A hearing is scheduled for June 03, 2005 at 9:30 AM in Courtroom No. 03. If the Status Report is filed prior to the hearing date, the hearing will automatically be cancelled. George r H ~f ~ r, P.J. Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone:(717) 240-6345 Date: 2/17/2006 FERRINO ROSEMARY 1229 KENAS ROAD NORTH WHALES, PA 19454-1207 RE: Estate of KLENK JOHN F File Number: 2002-00407 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 the Register of Wills a Status Report of completed or uncompleted administration. This filing is due by: 3/22/2006 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, Glenda Farner Strasbau Clerk of the Orphans' Court cc: File Personal Representative(s) ~I~~S TIC USTS Pr~oBAT~ ~aw Office of RosemarzJ P. ~errino 1228 Kenas I~oac~ Nort~i T ~a ~es, PA I g454-1202' (215)gg2=5s55 Cumberland County Register of Wills Cumberland County Court House One Court House Square Carlisle, PA 17013-3323 February 9, 2006 G ZIAI2DIANSHIP .~~D~IZ LATE" Dear Register: Enclosed please find for filing an Order dated December 13, 2005 from the Court of Common Pleas of Philadelphia County bearing the caption March, 2004 #01762. This order references survival damages approved by the Court in this case. Very truly yours, ~ ~. . ~~ .~ Y osemary errino, Esq. RRF:mh F £ r.'; ~F~"'i4-'~F, -~ ~ moo...-nr~ita A ~__ _..n !~ ---, --' f2~ ,~~ liL ly'F.~(y~ pn `~ ~,cM.g' tt~l n ~ ~ LL ~~ ~ 4j u V ~/ li.i~! ~>.1~~.i)~.!i p o:.V1! i! Ci'3 ~L.~U% t!.t::!1 tt~~ ~~~ ..~.~~! ! ,. _.~__._e__.,.... r~~~i „~. STAT~tTS ~E~©RT Uiv'DER RULE 6.12 ______ Name of Decedent: _ , ~~ ,P-E ~ ~ j~ ~, ~~ Date of Death: ~~Y~:.~,11 ~'~, ~c~~, Estate No.: ~ ~ G ~ - OL S~ ~' '7~ a Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate; 1. State whether ad anon of the estate is complete: Yes ~, No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: _ _ _/1'x,9 ~! ,~ v ~vd lv 3. If the answer to No. 1 is Yes, state the following: a. Did the personal representative f le a final account with the Court? Yes n No II b. The separate Orphans' Court No. (if any) for the personal representa~ve's account is: c. Did the personal representatnive state an account informally to the parties in ~,s r ~ ~;s ,~T I.LitG~'r tr ~ .' ~ L.1 ~,~ ,, c. Copies of receipts, releases, joinders and approval of formal or informal accounts maybe filed with the Clerk of the Orphans' Court and maybe attached to this report. ~-----~``~ --`"-" Date: v~ ~ ~ ~ ~ z-p Signature m,. ~.--- ~SF ~ `~'~l~ I Nv Name A ddl ess ~ ~ s ~~~~-~~~ ~ t'~~1~;~'~n;-ic I~Jr1 ~, __ G.ru.~'.lly: j ~ = L+t ~.G.1 viii 5~,114r.11,._~~' ~..~' J ~:~V'~~'r~ ~,i~ -~ ~iL Jri_!~ f i ~~1 GD41StG' LS~'v ~~ _ ~ ~,~ CJ'BRIEN & RYAI~i, LLP $y: Daniel F. Ryan, III Identification No. 27808 David L. Gordon Identif cation Na. S79S9 Hickory Pointe 2250 Hickory Road, Suite 300 PIyrnouth Meeting, PA l 9462- l 047 (610} 834-8800 ~l~ t~ ' ~~ V~ Attorneys for Plaintiff, - Francis G. Klenk, Administrator of the Estate of John F. Klenk, Deceased ~.~'~~~~ FRANCIS G. KLENK, ADMINISTRATOR OF THE ESTATE OF JOHN F. KLENK, DECEASED Plaintiff v. CLUB C~-IE1V115TRY, dlbla CHEMISTRY NIGI-JT SPOT, altla THE MAIN EVEI~iT, and RIVER DECK HOLDING CORPORATION d/bla CLUB CHEMISTRY, and MICHAEL HINCHEY Defendants COURT OF COA~iMON PLEAS OF PHILADELPHIA COUNTY : A~iARCH TERM, 2004 : NO. 1762 JURY TRIAL DEMANDED =~~- ORDER ANI) NOW, this ~ day of ~ ,-2005, upon consideration of the outstanding Petition for Approval of Settlement of Wrongful Death and ~_ Survival Actions, the proposed settlement with Francis G. Klenk, Administrator of the Estate of John F. Klenk, having a gross value of X765,000.00, is hereby approved, to be distributed and allocated as follows: } _ ,- ~. To: O'Brien 8~ Ryan, LLP $ 239,672. ~ 0 Counsel Fee To: O'Brien & Ryan, I_,f,P- $ 44,523.34 Reimbursement of Casts Wrongful Death Action To: Francis C. Klenk, father _ $ 432,724.10 Survival Action To: Francis C. Klenk, as Administrator of the $ 48,080.46 Estate of Sohn Klenk, deceased; provided, however, that Counsel shall not distribute any funds ~ to said Administrator until a copy of this order is filed with the Register of Wills of Cumberland County, and security, as may be required, is entered with the Register of Wills of Cumberland County with an approved corporate surety pursuant. to 20 Pa_C.S. § 3323(b}(3} is posted. Within sixty (60} days from the date of this Order, counsel for petitioner shall file an Affidavit with the Civil Motions Clerk (278 City Hall), certifying compliance with this Order_ The Affidavit shall bear the caption of the case and shall contain the court term and number. A copy of this Order shall be attached thereto. BY THE COURT: "- O'Keefe, 3. PURSUE TO Pa R p ~~~ DEC 1 3 2005 FIRSTJUDiCIAL ~~~ SPA USER I.D.: i c ' dry. Asa 1,., f`~N"}'A~~UCS 0.1~~ ~lMiLAAJ 4YA ~v~LltBklllW6".1~'sGLL1uS ~VJ~ai!i~L~% . ~~~ as ~ _ ,, ~,~ STATUS REPORT U~-DER RULE 6,12 Name of Decedent: ~ `~~0 I-4 N Date of Death: ~ a ~Ch ~2-~ ~ ~OOa Estate No.: ~ U D ~ ' ~U ~ d 'T Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the adminisuaticn of u're above-captioned estate: 1. State w her adminisri.~-ation of the estate is complete: Yes No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: /Y~~ ~ ~ ,~vo !~, _ _ ___ 3. If the answer to Na. 1 is Yes, state the following: a. Did the personal representative file a final account-with the Court? Yes [] No II b. The separate Orphans' Court No. (rf any) for the personal representative's account is: c. Did the personal representative state an account inforrl~ally to the parties in interest? Yes ~] No c. Copies of receipts, releases, joinders and approval of formal or informal accounts maybe filed with the Clerlc of the Orphans' Court and may be at*.achPd to this report. ~~"l ~~ Date; D ~ Si afore D,SF~ ` ~ F-' iZIC i nl ~ Name 1 aa9 k~~ ~ s i~~ ,~'o~~~ ti~~ ~s. Address G., x,15" `~ `~~,~~ TolF;,hn;~P IVn e' - -- r-----~ .4}:dCiy.` i~ j ~'ci~ _inl e~r~5eri~3'"';~'~ n .,:,~ sel FJ ~~ersor_al represe-ta~:ve .., ~, _; ~~ i`1~~-1-~U7 ti~ .J , i J R1 ~ Postage $ 0 Certlfled Fee I O D Return Receipt Fee sernent Required) ~~r O RestrictedDe~ry~rFe~d) ent ReQu r7 (Endorsem trt (U O a C`- Postmark Here ^ ComP~ Reins 1, 2, end 3. Also complete item 4 if Restricted Delivefy is dest-ed. ^ p~m your Hen's and address on the reverse ~ ttlat we can rett,lrn the card to you. ^ Attach ~~ card to the back of the mailpiece, or on the front 'tf space Pem,~s• 1, Article Addressed to: KLENK FRANCIS COURT 504 PARTRIDGE 1050 MECHANICSBURG PA ~ ~ ~ p .~ • ~ x+ ~. 8 , ~• ~ ~ ~' ~ Postage $ m p ~ Cert'rfied Fee ~ p Return Receipt Fee Postmark (Endorsement Required) Here p ~ Restricted Delivery Fee (Endorsement Required) ~rl IL TotelPostage 8 Fees p M o ~~ ~ n or PO Box No. City, §tare, Z1W~4 :~~ ~~ s A. Sign ^ Agent X Addre e) G. D to o De' B: Raceiv ~ (~ y r~Q~ D. le aelNery address different from item t? ^ Yes delivery address below: O No f~Certified Mail Ll Exp-ess Mail ^ Registered ^ Return Receipt for Merchandise... ^ Insured Mail ^ C.O.D• ^ Yes 4. Restricted Delivery? (Extra ~) 251^ 003 1244 681 2. article Number ? ^ Q 4 ~~fgr frp-R ierVECO fabeQ 102595-02•M-1540 porriestic Return Receipt PS Form 3811, February 2004 ^ Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. ^ Print your name and address on the reverse so that we can return the card to you. ^ Attach this card to the back of the mailpiece, or on.the front 'rf space permits. 1. article addressed to: /-. Signature ^ Agerrt X ~ , ^ Addressee 8: R v (PA-Ked C: Date of DelNery D. Is address different from item 1 ^ Y~ w delivery address bekrw: ^ No FERRINO ROSEM,~Y SUITE 300 2250 HICKORY RN~FA 19462 PLYMOUTH MEET_ .,Ne dCertified Maif ^ F.xprese Mail ^ Registered ^ Return Receipt for Merchandise ^ Insured-Mail ^ C.O.D. 4. ResMcted Delivery? (Extra Fee) ^ Yes Estate of KLENK JOHN F Late of HAMPDEN TOWNSHIP Estate No.: 21-02-00407 Date: 4/08/2005 FERRINO ROSEMAY 2250 HICKORY ROAD SUITE 300 PLYMOUTH MEETING PA 19462 ~;ie~ NOTICE OF FAILURE TO FILE STATUS REPORT AND REQUEST TO CONDUCT A HEARING PURSUANT TO RULE 6.12, SUPREME COURT ORPHANS' COURT RULE Personal Representative: KLENK FRANCIS Personal Representative Counsel: FERRINO ROSEMAY Date of Decedent's Death: 3/31/2002 Date of Delinquency Notice: 3/22/2005 The undersigned, Glenda Farner Strasbaugh, Clerk of Orhans' Court, in accordance with rule 6.12, Supreme Court Orphans' Court Rules, hereby notifies the Orphans' Court Division, Court of Common Pleas of Cumberland County, that neither the above named personal representative nor their counsel, have filed with the Register of Wills or Clerk of Orphans' Court, his/her Status Report required by Rule 6.12, Supreme Court Orphans' Court Rule, and that the requisite notice, pursuant to Rule 6.12, Supreme Court Orhans' Court Rules, was given by the Clerk of Orphans' Court on 3/03/2005 and that the ten (10) day notice to file the status report has expired. Accordingly, in accordance with Rule 6.12 the Court is hereby notified of such delinquency and the undersigned requests that a Court conduct a hearing to determine whether sanctions should be imposed upon the delinquent personal representative or their counsel. ~~~~ ~;~. cc: File Personal Representative Glenda Farner Strasbaugh Counsel Clerk of Orhans' Court A hearing is scheduled for June 03, 2005 at 9:30 AM in Courtroom No. 03. If the Status Report is filed prior to the hearing date, the hearing will automatically be cancelled. ',~. ti,. George ~ H r, P . J . ORPHANS' COURT DIVISION COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA NO.: 21-~02-00407 04/13/2005 11:11 FAX 6108341749 OBRIEN & RYAN LLP ~ 001/003 (,~' BRIEN tic RYAN. LLP ATiORNEY~ AT LAW Hkkory Poked! 2250 }IjeKOrY ~~..ciuft4 300 PIYtY+OVU+. PA 19462-1047 Msln: (61 ~ 834-BA00 FsOC: (6101 634-1749 WvV1N.ObMSw~om FAX COVER SHEE'N' HATE: ~ I X310 ~ FROM: ~a.•\ ~~t ~~ ~ NUMBER OF PAGES ~iCLUDING Tl~S COVER SHEET:. YOUR FAX NO: ~`7 t 7~ 2-H' o - ~ ~ `~ ? COMMENTS: 7FE uiFORNUITKNI CONTAM~D NTNIS FACSwOLE MFSSJIOE I$ ATTOfbaEY PRMLEGW AND CONFIDENML 6~ORMATION (MENDED ONLY FOR TiIE 1/$E OF TI{~ NJDIVIDUAL DR ENmY NAIAlD AbdVE. i 111E READER OF TM3 ME3,9ACsE IS NOT THE (MENDED REQIPIENT, YQ{J ARE HEREBY NOTIFIED Tt1AT ANY DKSE#BN11T10N,dSTRB1URON OR OOIYOFTM$ COMMN>aMCATON IS s;jTRIC7LY PROHBITEO. IF YOU HAVE RECENEDTHI$TRAFISMISSION IN ERROR, PLEASE NO11FY I1S IM1EO41TElY dY TELEPE1011E (OOLLECT) AT (610) 691-6600. .~, ?c!SM±tinf+;~!~V'4ut~kna~ransr^.e.,r`~ :.n,....a. , . 2~ ..7:N^: ~: ~ , . . .,:~3c'::. . ~... 04/13/2005 11:11 FAX 610834149 UBRIEN & RYAN LLP f~ 002/003 Ca' $RIi~~ & ~YAN, LLP q AT LAW t~daorY P~M~ T!i 90 tNd~rY R0~1R1.9~~ee BOG PIyA1~~ ~M. PlA tpq`$.10~T 1Y111~ d;! W o9~i•ee00 iilOC (6i~ s941T~Y www~hrtaw-oan Pad S ?e!1 D6iee! DiY: (61~ ~3M62?3 Fail: ppedAa6~1~++-eos Apri113, 2005 Y_ua Fa~7e aRd i~rJer Mil Register of Wills of Cumberland County Attn: Chhtietine thre Courthouse Square Carlisle, PA 17013 RE: Estate of Kiendc, JAhn F. Youx File No.: 2002-00407 can FGie No,:_ 91612 `~ ~ ~~ C°`~` Q~``-~ GY `~~ hear Christine: ~" ~~` Pursuant to our conversation this morning, enclosed please Snd the original and one (1) copy of the completed Rule 6.12 Status Report, dated February 16, 2005, on behalf of our client, the Estate of John F. Klenk. Kurdly file the original with the Court aadreturn a tune-stamped copy to nae in the self-addressed, stamped envelope enclosed herein. Please allow this letter to confirm that the Rule 6.12 hearing, scheduled for ]une 3, 2005, at 9:30 a.m. in Courtroom 3, is now cancelled in light of out filing of this status report. I~'my understanding is inaontect or you require any additional information, please contact me at your earliest opporttmity at the address and/or pho»e number providtd above. 'Thank you for your cooperaction grad courtesies in this matter. Very truly yours, ~' PAUL E. PEEL Enclosure cc; Glenda Fanner Stra4baugh, Esquire -Clerk of Orphans Court (w./er-e.) RENUNCIATION 21-2002-407 In Re Estate of ~.J~'J N / ~(C /P deceased. To the Register of Wills of ~U/71~ ~/`~~~~ County, Pennsylvania. The undersigned ~PN~ of the above decede~n_t,/ hereby r~e~noun/ce(s) the right to administer the estate and respectfully ask(s) that Letters 0~~ /C~-'rn1~U77~At'i0/~ be issued to ~~~~s WITNESS /~ ~ ~ ~_ . hand this day of ~ ~` ~ , ~Ud~ t ~~~. (" ~ ~(~ignature) -J C ~~. ~` ~ ~i4 / ~1S S o (Address) (Signature) S ~ t'Y1A E7, S, soooc i~fl~lL R~,sv~~ ~ i~ EC't'~~'VI C L fay rt ~ ~ ~ i`/OS.~ (Address) _ ~ _~_ __ ~ ~, ignature) (Address) /~~6~ yaa~~ O' BRIEN ~ RYAN, LLP ATTORNEYS AT LAW HICKORY POINTE 2250 HICKORY ROAD, SUITE 300 PLYMOUTH MEETING, PA 19462-1047 Main: (610) 834-8800 Flaa: (B10) 8341749 Rosemary R Feaino Direct Dial: (610) 8346270 Email: rfurino(rAobrlaw.com September 25, 2002 The Honorable George E. Hoffer 1 Courthouse Square Carlisle, PA 17013 RE: Estate of John Klenk No. OC - 0200407 Our File No: 91612 Dear Judge Hoffer: Enclosed please fmd a copy of the Petition for approval of a settlement being filed with the Clerk of the Orphan's Court in reference to settlement of the underinsured motorists coverage applicable in the death of Petitioner's 20 year old son. While technically such a settlement does not need court approval, (in that the estate does not involve a minor or a taxable estate) as I had explained to Ms. Gobrecht of your staff and discussed with court administrator Ms. Calvanelli, the insurance carrier involved is requiring "court approval" as it is their policy to do so. Further, since there was never a summons filed with regard to the underlying auto accident, Orphan's Court was the most appropriate forum to receive court approval. Therefore, while the Petition as filed provides for a citation and notice, if there is the opportunity to receive court approval without notice and a hearing (as all interested parties are in agreement) .Petitioner would welcome same. Finally, in that attorneys fees in this matter are not on a contingency basis but being incurred by Petitioner hourly, the approval of settlement without further need of counsel is of benefit to my client. B~espectf ours r -- ~~• ~ f~a G':'' ~~JM1 AR R. F:ERRINO RRF/j lm Enclosures ~ f 15056051058 REV- ^ 500 EX (06-05} OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Cade Year File Number PO BOX 280601 INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT 21 02 00407 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 181-62-6595 03/22/2002 11/06/1981 Decedent's Last Name Suffix Decedent's First Name MI Klenk John F (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 -~_:w' 2. Supplemental Return ;°:,::~ 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate ~'~,_:~~ 4a. Future Interest Compromise (date of ..:;.~ 5. Federal Estate Tax Return Required death after 12-12-82) 6. Decedent Died Testate ~:°'";.:°~ 7. Decedent Maintained a Living Trust _ _ _ _ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) ~ - 9. Litigation Proceeds Received ~::::~~: 10. Spousal Poverty Credit (date of death ~:~`~'~ 11. Election to tax under Sec. 9''#fi~(A) between 12-31-91 and 1-1-95 ~::.-~ (Attach Sch , t "- - ~~ ~ CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOttkp BE DIREC.b T0: G~ ~c~ -~., ~ ~-~ , _ Name Daytime Telephone Number .~ ; ;-::~:~ _ _- ~ . _ _, . _. Rosemary R Ferrino (215) 997-5855 _ -'_~ ~ . ~_ Firm Name (If Applicable) ,... ~ ` REGISTER OF WILtS JOSE Ot _,r-~ , -~ 4't _ _ ~ Law Office _ _ '- - ~ _. , . . First line of address - ~- ~ ' '~~^~ 1229 Kenas Road `° Second line of address City or Post Office DATE FILED State ZIP Code NORTH WALES PA 19454-1207 Correspondent's a-mail address: RRFERRINO@AOL.GOM Under penalties of perjury, i declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNAT PERSON RESP~BLE OR FI G RETURN DAT ADDRESS ? ~j ~t ~ J / ~y . /'~ _ _ ,~_6 '_~ ~,~~ /,~ car ~r~~'! RN rC s d i„~f~' /°// j ~V s© ____ SIGN F PREPAR REP SENTATIVE DATE ~ ~~ 04/19/06 ......fad 9 i~~~v~-s %'~/ ~f/o~-~ It1,~~~ ~~ i9~-.~ .r ~a ~ ~ PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 15056051058 J 15056052059 REV-1500 EX Decedent's Social Security Number John F Klenk 181-62-6595 Decedents rvame: ._ REC APITULATION _ _ 1. Real estate (Schedule A) . ............................................ 1. 2. Stocks and Bonds (Schedule B) ....................................... 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages & Notes Receivable (Schedule D) ............................. 4. 5. Cash, Bank Deposits 8~ Miscellaneous Personal Property (Schedule E) ........ 5. 432,724.10 6. Jointly Owned Property (Schedule F) ~::::~? Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers 8~ Miscellaneous Non-Probate Property (Schedule G) t=~"::a:~ Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1-7) .................................... 8. 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) ................................... 11. 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. 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. 432,724.10 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) x .0_ 432,724.10 15. 0.00 16. Amount of Line 14 taxable at lineal rate X .0 ~ 16. 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. _. ,. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAX DUE ......................................................... 19. 0.00 20. FILL {N THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 15056052059 Side 2 15056052059 REV-1500 EX Page 3 Decedent's Complete Address: File Number 2~ 02 00407 ~. AME _ John _ F Klenk STREET ADDRESS 504 Partridge Court -------------------------- CITY Mechanicsburg DECEDENT'S SOCIAL SECURITY NUMBER 181-62-6595 STATE PA ZIP 17050 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 0.00 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty (D + E) (3) 4. 1f Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) 0.00 Make Check Payable fo: 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 .......................................................................................................................... ^ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 2. If death occurred after December 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. 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 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 on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)). The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) (72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent (72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSUNAL PROPERTY ESTATE OF FILE NUMBER John F Klenk 02-00407 Include the proceeds of litigation and the date the proceeds were received by the estate. AN property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) -- .! -- - - ~~ C),'BRIEN & RYAN, LLP By: Daniel F. Ryan, III Identification No. 27808 David L. Gordon Identification No. 57959 ~!-Iickory Pointe 2250 Hickory Road, Suite 300 Plymouth Meeting, PA 1 9462-1 047 (6I0} 834-8800 Attorneys far Plaintiff, Francis G. Klenk, Administrator of the Estate of John F. Klenk, Deceased ~~~~~~ FRANCIS G. KLEN~K, ADMINISTRATOR OF THE ESTATE OF JOHN F. KLENK, DECEASED Plaintiff v. CLUB CI-IEMIST:RY, d~bia C:I-IEMIS"IvRY NIGHT SPOT, a/Ua "THE MAIN EVENT, and RIVER DECK 1-I OLDIN G CORPORATION d1b/a CLUB CI-IEMIS"I~RY, and MICI-IAE:L I=lTNCI-iEY Defendants COtTRT OF COMMON PLEAS OF PHILADELPHIA COLfNTY IvIARCI-i TERM, 2004 NO. I762 JURY TRIAL DEMANDED ~~. ORDER A.ND NOW, this C day of ~ ,.2005, upon consideration of the outstanding Petition for Approval of Settlement of Wrongful Death and Survival Actions, the proposed settlement with Francis G. Klenk, Administrator of the Estate of John F. Klenk, having a gross valve of $765,000.00, is hereby approved, to be distributed and ~illoc~~ted as follows. To: O'Brien & Ryan, LLP $ 239,672.10 Counsel Fee To: O'Brien & Ryan, LLP. $ 44,523.34 Reimbursement of Costs Wrongful Death Action To: Francis G. Klenk, father $ 432,?24.10 Survival Action To: Francis G. Klenk, as Administrator of the $ 48,080.46 Estate of John Klenk, deceased; provided, however, that Counsel shall not distribute any funds to said Administrator until a copy of this order is filed with the Register of Wills of Cumberland County, and security, as may be required, is entered with the Register of Wills of Cumberland County with an approved corporate surety pursuant to 20 Pa.C.S. § 3323(b).(3) is posted. Within sixty (b0) days from the date of this Order, counsel for petitioner shall f le an Affidavit with the Civil 3Ylotions Clerk (278 City Ha11), certifying compliance with this Order_ The Affidavit shall bear the caption of the case and shall contain the court term and number_ A copy of this Order shall be attached thereto. BX THE COURT: O'Keefe, 3. PURSUAN ~TO a R P 236{b) DEC 13 2005 FIRSTJUD~CtAL jR~ USER I.p,. ~ OFPA ~~~~z- ~~ O'BRIEN & RYAN, LLP By: Daniel F. Ryan, III Identification No. 27808 David L. Gordon Identification No. 57959 Hickory Pointe 2250 Hickory Road, Suite 300 Plymouth Meeting, PA 19462-1047 (610) 834-8800 Attorneys for Plaintiff, Francis G. Klenk, Administrator of the Estate of John F. Klenk, Deceased FRANCIS G. KLENK, ADMINISTRATOR OF THE ESTATE OF JOHN F. KLENK, DECEASED Plaintiff v. CLUB CHEMISTRY, dlb/a CHEMISTRY NIGHT SPOT, a/t/a THE MAIN EVENT, and RNER DECK HOLDING CORPORATION d/b/a CLUB CHEMISTRY, and MICHAEL HINCHEY Defendants COURT OF COMMON PLEAS OF PHILADELPHIA COUNTY MARCH TERM, 2004 NO. 1762 JURY TRIAL DEMANDED AFFIDAVIT OF WRONGFUL DEATH AND SURVIVAL ACTION DISTRIBUTION I, DANIEL F. RYAN, being duly sworn state: 1. I am coul~sel for the Plaintiff in the above-captioned matter. 2. On January 5, 2006, Francis G. Klenk, Administrator of the Estate of John F. Klenk, received distribution of the settlement funds in accordance with the Court's Order, dated December 13, 2005. See attached as Exhibit "A." 3. The settlement funds were distributed in accordance with the Court approved Statement of Distribution. See attached as Exhibit "B." DANIEL F. RYAN, III Sworn to and subscribed before me this ~ day of .~~.~- ~ Q.r , 2006. Notary Publi COMMONWEALTH OF PENNSYLVANIA Notarial Seal Kathryn G. Drakeley, Notary Pt~liC Plymouth Twp., Ma~tgornery CotrYty My Corrxnlsslon E~ires Mar_ 12, 2009 Mlmbor, Pennsylvania Association of Notaries REV•1513 EX+ (9-00) ~ v COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER John F Klenk 02-00407 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE ~ TAXABLE DISTRIBUTIONS (include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] ~ Francis G Klenk Father 50.00 2 Mary Agnes Klenk Mother 50.00 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET [1 NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET I $ 0.00 (If more space is needed, insert additional sheets of the same size) /{ f _~ (f'~ l~`:': ~ . R~,~~1~0.~~' ~1 W'NLL~u~ ~LYk ~~.+4i1Y~11t19~:Ji'PtrliAal ~.hYZ1iu~L~% . ~~ ~ ~~ STATUS REPORT UNDER RULE 6. I2 Name of Decedent: ~ ~p ~4 N Date of Death: _ ,/~ Q ~'Ch ~2; 2~ a..p p~ Estate No.: e~ U U c~ - ~U ~ d ~r Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the admuzist<aticn of LL'~e above-ca~tiuned estate: 1. State w er adminisuation of the estate is complete: Yes No ~' 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: /nA~ vo l 3. If the answer to No. 1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes L] No II b. The separate Orphans' Court No. (if any} for the personal representative's account is: c. Did the personal representative state an account inforr~~ally to the parties in interest? Yes n No c. Copies of receipts, releases, joinders and approval of formal or informal accounts may be filed with the Clerk df the Orphans' Court and ~,ay be at~ached tc this report. ~~~ ~---"" ~~ Date; Q (,~ Si afore ._.--- Name ~.. Address ~: ~~, , ~ .., ~ f 5" 9_q.7~8,55 ,' ~ ~ TPIPS~hn_~p N0. /"~ r J mar ~^11y~`z~rj _'Gi :sad ~rt'eSeri~3::V~ ~,../~' ,op~sel fjr ~erSCri21?'ep_ese-taive 1,,J~~ v~ /-' ~l v COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TARE ~,,,,~.,,.;- NOTICE OF INHERITANCE TAX INHERITANCE TAX DIVISION ~_ r' ~`:-~ hISEMENT, ALLOYIANCE OR DISALLOWANCE ~~~' ~'~`t ~ -AF~DEDUCTIONS AND ASSESSMENT OF TAX Po sox 2aobol ,, ~ , ~ r- ~,. HARRISBURG PA 17128-0601 ~ i ,` ',.'i --- REV-1547 EX AFP (06-OS) DATE 07-10-2006 ~(~~, ,~~~ I ~ ~~~~ ~ ~ ' ~g ESTATE OF KLENK JOHN F DATE OF DEATH 03-22-2002 ~~~~~~~( ;_;;= FILE NUMBER 21 02-0407 r~i_ j ~: ! '^; COUNTY CUMBERLAND ROSEMARY R FERRI~f~~~~Sit `' ACN 101 OBRIEN & RYAN ~~-~'~' APPEAL DATE: 09-08-2006 1229 KENAS ROAD (See reverse side under Objections) NORTH WALES PA 19454-1207 A(~ount Resitted MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE- -~ RETAIN LOWER PORTION FOR YOUR RECORDS F- ------------ ----------------------------------------------------------------------- REV-1547 EX AFP (03-05) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF KLENK JOHN F FILE N0. 21 02-0407 ACN 101 DATE 07-10-2006 TAX RETURN NAS: (X) ACCEPTED AS FILED ( l CHANCED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: SUPPLEMENTAL RETURN N0. O1 1. Real Estate (Schedule A) (1) .00 NOTE: To insure proper 2. Stocks and Bonds (Schedule B) (2) .00 credit to your account, 3. Closely Held Stock/Partnership Interest (Schedule C) [3) .0 0 subwit the upper portion of this fora with your 4. Mortgages/Notes Receivable (Schedule D) (4) .00 tax paywent. 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) 432,724.10 6. Jointly Owned Property (Schedule F) (6) .00 7. Transfers (Schedule G) (7) .00 8. Total Assets (g) 432, 724.10 APPROVED DEDUCTIONS AND EXEMPTIONS: .00 9. Funeral Expenses/Ada. Costs/Misc. Expenses (Schedule H) (9) 10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) .00 11. Total Deductions (11) _00 12. Net Value of Tax Return (12) 432,724.10 13. Charitable/Govarnasntal Bequests; Non-elected 9113 Trusts (Schedule J) (13) .00 14. Nst Value of Estate Sub3ect to Tax (14) 882,402.60 NOTE: if an assesssent was issued previously, lines 14, 15 andior 16, 17, 18 and 19 Niii rs~lect i'igures that include the total o~ ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate (15) 882,402.60 X 00 _ .00 16. Amount of Line 14 taxable at Lineal/Class A rats (161 .00 X 045 . .00 17. Amount of Line 14 at Sibling rate (17) .00 X 1 2 .00 18. Amount of Line 14 taxable at Collateral/Class B rate (18) •00 X 1 5 - .00 19. Principal Tax Dw (19). .00 DATE ~ NUMBER ~ INTEREST/PEN PAID (-) I AMOUNT PAID TOTAL TAX CREDIT .00 tALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 * IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF A~ITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN Sl, 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.)