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02-0408
PETITION FOR GRANT OF LETTERS OF ADMINISTRATION Estate of Q C..fj L, 6vJJu /-AJ also known as :l1-tJ:l. -(/fJl' No. To: Register of Wills for the County o~'{,. ,4,,,h<....{w,f.- in the Commonwealth of Pennsylvania .. peceased. Social Security No. L t.t 1; - s ( - ~ 1 <./ ( The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older, appl ("L( for letters of administration on the estate of (d.b.n.; pendente lite; durante absentia; durante minoritate) the above decedent. Decendent was domiciled at death in ~ h (;) last family or principal residence at J-OtJ 1- ,~ 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 pe~SYlvania situated as follows: bliP. $ J; d 10 $ $ $ Petitioner_ after a proper search h~ ascertained that decedent left no will and was survived by the following spouse (if any) and heirs: ~~, WIP- THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the appropriate form to the undersigned. t L/~n-.~~ ~'i::' Wp(~~ Pl... &- t,,(} ~ g -< I), f- 5"~'~ s+ - 19 meek I? \/0 s; ~ 3~ <>4-< .so '" 0:: eo U3 17-59-.3 b'!7l ~ n I <:s 6fJ (It, OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PJ:NNSYLVANIA COUNTY OF (h .t... b,^-~ } ~,""'- sS~"':" 3 ~. d N = W ;<J 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. o -0 t.~ , "v i::S I,,-,ii- y subscribed I .'irL- it- day of L ',~) elt- 2002 Register ~ ~- W\ ~ 8f)ji~ e c"" \ t..4 i ~) --- '" '-" (I) ... ::s .... tU = l:lIl Ci.i Sworn to or affirmed and before me this 10th April Estate of No. 21-2002-408 ,~ LI,Jk,/{ (tl'rW . , Deceased GRANT OF LETTERS OF ADMINISTRATION AND NOW April 24th D; 200~ in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, lT IS DECREED that Ga:ry T, _ Rn 1 nwi n is/antentitled to Letters of Administration, and in accord with such finding, Letters of Administration are hereby granted to Linda M.Baldwin in the estate of Gary L. Baldwin Mary c. ~~ FEES Letters of Administration Short Certificates( 5) . . . . . . . . . . Renunciation ................ JCP aAi)lJ.~J-'l.fiv /\ ATTORNEY (S~p. Ct. I.I?' No.) t, _'_/ -hail ~ 'it tfll A-~ e jUCv(At' S't~ MfJ~l vS 'Of / ADDRESS (7 /7") - 715 - f 7 9 0 $ 25.00 $ 1 5 00 $ $ 5 . 00 TOTAL _ $ 45.00 Filed N:l:r;-iJ-. .24. . . . . .20.Q2 A.D. UJXXX- PHONE MAILED LETTERS TO ATTORNEY H105.905 REV.(09/00) This is to certify that this is a true copy of the record which is on file in the Pennsylvania Division of Vital Records III accordance with Act 66, P.L. 304, approved by the General Assembly, June 29, 1953. WARNING: It is illegal to duplicate this copy by photostat or photograph. No. ~!I~ G\~s.~/~, Robert S.<Ziminerman, Jr., MPH Secretary of Health Charles Hardester State Registrar 1869748 APR f1l002 Date REPLACES onGINAL Hl05.144;".v. '~T FOR. ITEK(S): 4 COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS TYPE/PRINT SIGNED: 3-17-02 FILED: 3-20-02 CERTIFICATE OF DEATH PER~:NENT 4-17-02bas (Coroner) BLACK INK 02!)347 SEX STATE FIlE NUMBER SOCIAL SECUFlITY NUMBER UNDER 1 OM Hours Minutes BIRTHPlACE (Cily and State or Foreign Country) ='YI!U Adams DECEDENT'S USUAL OCCUPATION (~~~':lir.~:o~u~r;~r~)' . "0. Associ ate "f:1anufacturi ng DECEDENT'S MAtllNG ADDRESS (Stree!. Cilyrrown. Stale, Zip Code) DECEDENT'S 12 E Green Street ~~~~~iNCE (See instructions t.1echani csburg Pa. 17055 on""'.'_) FATHER'S NAME (Firsl. Middle, last) ,.. C h a r 1 e s B a 1 d win INFORMANT'S NAME (Type/Print) MARITAL STATUS. Married Never Married. Widowed. Divorced (Specily) ...Marri ed SURVIVlNG SPOUSE (II wile. give maiden name) 17&. Slale 17C.O Yes, deced8nllive<l in twp. 17b. Count Cumberl and 17dn~~h:::"'=:=of MOTHER'S NAME (First. Middle, Malden Surname) Martha Schreffler cIty_o LICENSE NUMBER 2". Fd-012755-L s Pa 17007 21c. Cumberland Valley NAME AND ADDRESS OF FACIUTY 22t!yers F.H. 37 LICENSE NUMBER Pa. E Main St MBG, Pa. DATE SIGNED (Month. Cay, Year) 23b. 23c. 'M.S CASE REFERRED TO MEDICAL EXAMINERlCOAONER? Ye.. NoD 17055 DATE PRONOUNCED DEAD ~Month, Day, Year) 24. O'l: IS .1 M. 25. /P'I""'-,,/" /1.&, . oo'l.. 27. PART I: Enter the dl....... injurtes or complications which calJHd the death. Do not enter the mode of dying. such as cardiac Of respiratory arrest. shock Of heart failure. Ust only one cause on each line. b. t!a~ '1" 2.. IApproximate I inlerval between ! onset end death PART II: Other significant conditions contributing to death. but not resuhlng In lhe underlying cause given In PART I. DUE TO (OR AS A CONSEQUENCE Of): Ye.o No D Accident D Homtcide D . Pending Investigalion D D Could not be determined D ... " ,",::l. 3Gb. ~7: Is'. P E OF INJURY. At home. 'arm. street. factory. oflice buikllng. etc. (Specily) 300. Ie tzj) d. WERE AUlOPSY FINDINGS MANNER OF DEATH AVAILABLE PRIOR 10 COMPLETION OF CAUSE OF DEATH? Natural D.ATE OF INJURY (Month, Day, 'l8ar) TIME OF INJURY 01'" tIrc.- 2... 21b. CERTIFIER (Check only one) -CERTIFYING PHYSICIAN (Physician C8fliIying cause of dealh when another physician has pronounced dealh and completed Item 23) Ta1hebHtotmyknow....drnthOCCUrnddue101heCIIUH(.)andmlln....r...1IIIad..."...........,.........,........,..............,. . Suicide 21. .... z w o W \ frl o u. o w " < z D3'b.~ LICENSE NUMBER 'PRONOUNClNG AND CERTIFYING PHYSICIAN (Physician bolh pronOl.lncinQ death and certifying to cause 01 death) Ta the bnt of my knowtedge, dHth accurred.1 the time, .... and~. and due Ia the ~H(.).nd mII......r.. ItIited.. . , . , . . . . . . . . . . . . , . , . . . . . .MEDICAL EXAMINER/CORONER ~~~~:t::=~~~t,~ .~~~~~~~~~~~t.~~: ~~ ~.y. ~~,n,,~~: ~~~~~:~~~ ~ ~~ ~I~~..~~~: ~~.~~: ~.~~~~~~ :~~~J,~~ . 31., REGISTRAR'SSIGM'A-rE' .~ _~ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPARTMENT 280601 HARRISBURG, PA 17128-0601 Telephone 7/ 19/2002 717-783-0972 David W Knauer, Esquire Knauer & Associates 411A East Main Street Mechanicsburg, Pa 17055 Re: Estate of Gary L Baldwin File Number: 2102-0408 Court Number: Cumberland-Orphans-21-02-0408 2002 Dear Mr. Knauer: The Department of Revenue has received the Petition for Approval of Settlement Claim to be filed on behalf of the above-referenced Estate in regard to a wrongful death and survival action. It has been forwarded to this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to settle the actions. Pursuant to the Petition, the 54 year old decedent died as a result of a motor vehicle accident. Decedent is survived by the decedent's spouse and two adult children from a prior marriage. Please be advised that, based upon these facts and for inheritance tax purposes only, this Department has no objection to the proposed allocation of the gross proceeds of this action, $ 80,000.00 to the wrongful death claim and $ 20,000.00 to the survival claim. Proceeds of a survival action are an asset included in the decedent's estate and are subject to the imposition of Pennsylvania inheritance tax. 42 Pa.C.S.A. §8302; 72 P.S, §§9106, 9107. Costs and fees must be deducted in the same percentages as the proceeds are allocated. In re Estate of Merryman, 669 A.2d 1059 (Pa. Cmwlth. 1995). I trust that this letter is a sufficient representation of the Department's position on this matter. As the Department has no objections to the Petition, an attorney from the Department of Revenue will not be attending any hearing regarding it. Please contact me if you or the Court has any questions or requires anything additional from this Bureau. Finally, the approval of this allocation is limited to this estate and does not reflect the position that the Department may take in any other proposed distribution of proceeds of a wrongful death /survival action. Sincerely, L 1 ert" Inheritance Ta.x Division Bureau of Individual Taxes cc: Cumberland County Clerk of Orphans Courts r ~UL ~ ~ ZOOI IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA IN RE: ESTATE OF GARY L. BALDWIN, No. 21-02-0408 2002 Deceased Civil Action Orphans Court ORDER AND NOW, this ,~~ ~ ~ day of July, 2002, upon consideration of the attached Petition for the Approval of Settlement Offer, it is hereby ORDERED and DECREED that the aforesaid petition is hereby set down for hearing on the ~ day of , 2002 at i .'vDlz~'1. in Courtroom _~. By the Court, `_, ~~ IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA IN RE: ESTATE OF GARY L. BALDWIN, No. 21-02-0408 2002 Deceased Civil Action Orphans Court ORDER AND NOW, this day of July, 2, upon consideration of the attached Petition fo he Approval of l ent Offer, it is herby RED and ~ , DECREED tha a aforesaid p ion i ereby GRANTE ubject ~ the filing of Affidavits o ary L. Baldw' , Jr., aron Baldwin a 'Linda M. aldwin in her represe ative capac' as Ad istratrix of th state of Ga L. Baldwin and i her n individu capacity. consenting t , the proposed vision of th ~ ~stat of „~ ry L. Bal `in and an idavit fro she Commonw lth of Pe sylvan' , ~' ~ Depart ent of Revenu ,Inherit ce Division cons nting t e appo on t of th ettlement betwe th ~urvival Action Clai and a Wran I , th Claim. Cou J. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA IN RE: ESTATE OF GARY L. BALDWIN, No. 21-02-0408 2002 Deceased Civil Action ,, ;. . . Orphans Court PETITION FOR THE APPROVAL OF SETTLEMEKT OFFER 1. On March 16, 2001, the Decedent and his wife, Linda M. Baldwin were traveling south on Route 15 in Adams County, Pennsylvania on a trip to visit family in the Commonwealth of Virginia. 2. On the aforesaid date, Matthew Kernan was traveling north on Route 15 in Adams County, Pennsylvania at an excessive rate of speed and was operating his vehicle negligently. 3. As the Baldwin vehicle and the Kernan vehicle were approaching each other in opposite directions, Kernan so operated his vehicle negligently that it came across the grass between the north and south lanes of travel on Route 15 and struck the Baldwin vehicle head-on. 4. The force of the collision instantly killed both the Decedent and Kernan and seriously injured Linda M. Baldwin. 5. As of the date of his death, the Decedent had attained his fifty-fourth birthday. 6. As of the date of his death, the Decedent was employed by the Square D Company that was his employer for the entire calendar year of 2001 through to the date of his death. The aforesaid employer paid unto the Decedent Wages, in the amount of $34,948.47. The Administratrix marks as Exhibit "A", attaches hereto and incorporates herein by reference thereto a copy of the Decedent's W-2 Form for calendar year 2001. 7. The Register of Wills appointed Linda M. Baldwin Adminsitratrix of the Decedent's estate. 8. The Executrix and two adult children of the Decedent by another marriage survived the Decedent. 9. Kernan had $100,000/$300,000 of vehicular insurance through Nationwide Assurance Company. Nationwide tendered the policy limit of $100,000 for the Decedent for the claim. 10. The Decedent and the Administratrix had a single limit underinsured motor vehicle insurance in the amount of $100,000 through the Westfield group formerly known as Old Guard Insurance Company. 11. The Westfield Group has offered its single limit $100,001) and will make payment upon Your Honorable Court's approval of Westfield Group's offer of its policy limit. 12. The Administratrix's and Estate's claims both exceed the maximum of Oinsurance coverage available. 13. The proposed division of the single limit Underinsured Limit of $100, 000 is $50,000 for the Decedent and $50,000 for the Administratrix. 14. The adult children of the Decedent, Gary L. Baldwin, Jr. ;and Sharon Baldwin and Linda Baldwin in her own capacity and not in her representative capacity as Administratrix of the Estate of Gary L. Baldwin are in agreement with the division of Underinsured Limit of $100,000 as aforesaid. 15. Pursuant to 20 Pa.C.S.A. 2102(4), after deduction of costs and fees, the net of the proposed settlement of $150,000 for the Decedent's estate will be divided fifty (50%) percent to Linda M. Baldwin, Administratrix, (25%) for Gary L. Baldwin, Jr. and twenty five (25%) for Sharon Baldwin. 16. Administratrix has contacted the Commonwealth of Pennsylvania, Department of Revenue, Division of Inheritance Tax, and has proposed a division of the proposed total settlement for the Estate between the Survival Action claim and the Wrongful Death Action claim. 17. The Administratrix's undersigned counsel will be out of the office on vacation until July 22, 2002. He has sent proposed Affidavits to the adult children of the decedent and to the Division of Inheritance. The Administratrix anticipates that either before or shortly after the Administratrix's counsel returns from vacation that he will have received or will receive the aforesaid Affidavits. Adminsitratrix's counsel will file the Affidavits he receives as soon as practicable after his return from vacation. WHEREFORE, the Administratrix prays that Your Honorable Court will approve the settlement of the aforesaid Decedent's Underinsured Motorist Claim as aforesaid. Respectfully submitted, KNAUER & ASSOCIATES, L.S.C. Q ~~ , David W. Knauer, Esquire Attorney for Plaintiff Attorney I.D. No. 2158:>. 411-A East Main Street Mechanicsburg, PA 170:55 Date: July 10, 2002 (717) 795-7790 33332.29 4948.21 Social seeurtty wages { social security tax withheld This summary section is included with your W-2 to help de;tribe this 34948.47 2166.81 pottier in more detail. The reverse side includes general information that Mediearewapesandtips 6 Mediuretaxwithheld -y0U may also find hetppfut. The following reflects youf~ final pay stub. plus 349 48.47 506.75 any adjustments made by your employer. Control Number Dept ; Corp. Employer use only GROSS PAY 35,350.95 SOCIAL SECURITY 2,166.81 .00927 W7L ;M120 F 3176 TAX WITHHELD Emplger's name, address, and ZIP code BOX 04 OF W-2 SQUARE D COMPANY FED. INCOME ~ 4,948.21 MEDICARE TAX 506.75 1415 SOUTH ROSELLE ROAD TAX WITHHELD WITHHELD PALATINE, IL 60067-7399 BOX 02 OF W-2 BOX 06 OF W-2 DS355D759 STATE INCOME TAX 978.48 SUI/SDI 0.00 BOX 17 OF W-2 BOX 14 OF W-2 LOCAL INCOME TAX 353.50 Emplger s DID number d Emplgec's SSA number BOX 19 OF W-2 30-L~V•iVOOO r oa-ao- or v l Social tceeuriy tips 8 Allocried tips Advanu EIC payment 10 Dependent care benefits Other Emplgee's name, address ana ZIP code GARY L BALDWIN 12 E GREEN STREET MECHANICSBURG, PA 17055 353.50 WSTB te, accurate, Visit the IR Web t~ sTl use at arnvntrars.gw. Employee Reference Copy ~~~ WStat me tax ~oo To change your employee W-4 profile information file a new W-4 with your payroll department 17055 Exemptions/Allowances: Federal: 0 state: o Local: 0 SLte Emplger's stale ID no. 16 State wages, tips, rio. 186 6797 State income tax 18 Lou- wages, tips, ere. Social Security Number. 195J8-8791 978.48 35350.95 GARY L BALDWIN TaxablcMarilal5tatus: Local ineometax 20 Locally name 12 E GREEN STREET SINGLE IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA IN RE: Estate of Gary L. Baldwin Deceased Case No: 21-02-0408-2002 Civil Action, Orphans Court AFFIDAVIT 1. That your affiant is over 18 years of age and is competent to be a witness in this matter. 2. I, Sharon Baldwin, am the daughter of Gary L. Baldwin, Sr.; that Gary L. Baldwin, Sr. had two children by his first marriage, being myself and my brother, Gary Baldwin, Jr.; that both myself and my brother Gary Baldwin, Jr., are adult individuals; that David W. Knauer, Esquire, counsel for the Administrix Linda M. Baldwin has provided me with a copy of the Petition for the Approval of Settlement Offer; that David W. Knauer, Esquire has recommended that I obtain my own independent counsel to review the aforesaid Petition for the Approval of Settlement Offer if I so desire; that I have read and am in agreement with both the settlement amount for the Westfield Group Underinsured Limite of $100,00 and the division of the $100,000 settlement to be divided $50,000 for the claim of the Estate and $50,000 for the claim of Linda M. Baldwin in her own right for her personal injuries and not in her position as Administratrix of the Estate; the division of the $50,000 for the claim of Linda M. Baldwin in her own right for her personal injuries and not in her position as Administratrix ofthe Estate; the division of the $50,000 portion ofthe Westfield Group as settlement after deduction of expenses and fees shall be divided in the percentage of Twenty-five (25%) percent of the net settlement for myself, Twenty-five (25%) percent ofthe net settlement for my brother, Gary Baldwin, Jr., and fifty (50%) percent of the net settlement for Linda M. Baldwin, widow and Administratrix ', of the Estate of Gary L. Baldwin; the Affiant sayeth not further. ~,i i i ,~ti Sharon Baldwin SWORN to before me this ~~ day of S~' , 2002. EDWARD N. BUTTON, P.C. ATTORNEY AT LAW 20 W. WASHINGTON ST. SUITE 501 HAGERSTOWN, MD21740 ~~ ~ ~~; ~~ ~ ~ ©~ 1~Totary Public lay~y Commission Expires: 3/01/03 2 (301)739-4860 CERTIFICATION OF NOTICE UNDER RULE 5.6~a~ Name of Decedent: GARY L. BALDWIN Date of Death: March 16. 2002 Will No. 2002-00408 Admin. No. To the Register: I certify that notice of beneficial interest required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on _M~ 2, 2002 Name Address Linda M Baldwin Widow & Administratrix - 12 E. Green St., Mechanicsburg, PA. Opened Estate 17055 Gary Baldwin Jr Son - 803 Royal Crest Dr., Martinsburg, WV' 25401 Sharon Baldwin Daughter - 211 E Washington St., Hagerstown, MD 21740 Notice has now been given to all persons entitled thereto under Rule 5.6 (a) except Date: _August 1, 2002 nature Name: David W. Knauer Address: 411A E. Main Street Mechanicsburg=PA 17055 Telephone: 717 795-7790 Capacity: Personal Representative X Counsel for personal representative Knauer & Associates, LSC Attorneys-at Law 411A. East Main Street, Mechanicsburg, PA 170.55 Telephone: (717) 795-7790 Fax: (717) 795-7793 Email: knauer@early.com David W. Knauer August 2, 2002 Curtis R. Long Cumberland County Prothonotary One Courthouse Square Carlisle, PA 17013 RE: Baldwin Estate Dear Mr. Long: Please find enclosed for filing a Notice of Hearing regarding the above matter. Thank you. DWK: bm Enclosure CC: Linda Baldwin Gary Baldwin, Jr. Sharon Baldwin Company\Baldwin\08-02-02\ltr ~.: ~, ~7 Ve y yours, ~~ ~~~ ~~ David W. Kn uer 4 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA IN RE: ESTATE OF GARY L. BALDWIN, No. 21-02-040&-' Deceased Civil Action Orphans Court NOTICE OF HEARING On the PETITION FOR THE APPROVAL OF SETTLEMENT OFFER filed by Linda M. Baldwin, Administratrix of the Estate of Gary L. Baldwin, the Honorable George E. Hoffer has scheduled a hearing on Monday, the 19th day of August, 2002 at 11:00 a.m. in Courtroom Number ~ ,Cumberland County Courthouse, at the intersection of High Street and Hanover Street, Carlisle, Pennsylvania to take testimony on the aforesaid Petition. The purpose of the hearing is to request court approval of a One Hundred Thousand Dollar ($100,000) settlement offer that the Westfield Group made for settlement of the Underinsured Motorist single limit portion of the joint policy that Gary L. Baldwin and Linda M. Baldwin purchased prior to the death of Gary L. Baldwin and the serious injury of Linda M. Baldwin. The proposed division of the aforesaid settlement offer of the Westfield Group is that Fifty Thousand Dollars ($50,000) be paid to the Linda M. Baldwin, Administratrix of the Estate of Gary L. Baldwin and Fifty Thousand Dollars ($50,000) to be paid to Linda M. Baldwin for her own personal loss and damages. The proposed settlement amount of Fifty Thousand Dollars 1;$50,000) to be paid to Linda M. Baldwin in her capacity as Administratrix of the Estate of Gary L. Baldwin would then after payment of costs any expenses be divided with fifty percent (50%) paid to Linda M. Baldwin and Fifty Percent (50%) divided equally between Gary L. Baldwin, Jr. and Sharon Baldwin, the children of Gary L. Baldwin by a prior marriage. If you have any questions or wish to introduce any evidence for the Court's consideration, this will be the only opportunity to present those questions or introduce any evidence that you might wish to produce whether in support of the proposed allocation or against the proposed allocation. After the Court rules on the aforesaid Petition there will be no further opportunity to support or object to the proposed allocation of the Westfield Group's One Hundred Thousand Dollar 1;$100,000). If you the right to retain an attorney to represent you with respect to the proposed allocation. Respectfully submitted, KNAUER & ASSOCIATES, L.S.C. ,] v ~~~- ~~ David W. auer, squire Attorney for Plaintiff Attorney I.D. No. 21582 411-A East Main Street: Mechanicsburg, PA 17055 Date: August 1, 2002 (717) 795-7790 _ r--- IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA ' IN RE: ESTATE OF GARY L. BALDWIN, No. 21-02-0408 2002 Deceased Civil Action Orphans Court ORDER AND NOW, THIS DAY OF August, 2002, upan consideration of the Petition for the Approval of Settlement Offer of Linda M. Baldwin Administratrix of the Estate of Gary L. Baldwin and after hearing held this 19tH day of August, 2002, it is hereby ORDERED and DECREED that the aforesaid Petition is hereby GRANTED and the aforesaid Administratrix is hereby authorized to accept the tender of the decedent's and Administratrix's automobile insurance carrier's Underinsured Motorist single policy limit in the amount of $100,000. Their insurer is the Westfield Group; formerly Old Guard Insurance Company, and It is further ORDERED and DECREED that the aforesaid Underinsured Motorist single limit policy limit in the amount of $100,000 is to be divided equally between the Linda M. Baldwin Administratrix of the Estate Gary L. Baldwin in her representative capacity and Linda M. Baldwin in her own right. By the Court, e e .Hoffer, J i IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANLA ~~~ f , . .f ~.~ . , ~~ IN RE: ESTATE OF GARY L. BALDWIN, No. 21-OZ-0408 2002 Deceased Civil Action ; '. Orphans Court AFFIDAVIT OF GARY L. BALDWIN. JR. I, Gary L. Baldwin, Jr., am the son of Gary L. Baldwin, Sr.; that Gary L. Baldwin Sr. had two children by his first marriage being myself and my sister Sharon Baldwin; that both myself and my sister Sharon Baldwin are adult individuals; that David W. Knauer, Esquire, counsel for the Administratrix Linda M. Baldwin has provided me with a copy of the Petition for the Approval of Settlement Offer; that David W. Knauer, Esquire has recommended that I obtain my own independent counsel to review the aforesaid Petition for the Approval of Settlement Offer if I so desire; that I have read and understood the aforesaid Petition for the Approval of Settlement Offer; that I am in agreement with both the settlement amount for the Westfield Group Underinsured Limit of $100,000 and the division of the $100,000 settlement to be dividf;d $50,000 for the claim of the Estate and $50,000 for the claim of Linda M. Baldwin iin her own right for her personal injuries and not in her position as Administratrix of the; Estate; the division of the $50,000 portion of the Westfield Group as settlement after deduction of expenses and fees shall be divided in the percentage of twenty five (25%) percent of the net settlement for myself, twenty five (25%) percent of the net settlement for my sister, Sharon Baldwin and fifty (50%) percent of the net settlement for Linda M. Baldwin, ., . . widow and Administratrix of the Estate of Gary L. Baldwin; the Affiant sayeth not further. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA IN RE: ESTATE OF GARY L. BALDWIN, - No. 2i-02-0408 :2002 ` ~ Deceased Civil Action ~ Orphans Court 3 m F~XHIBITS EXHIBIT DATE PERSONS A May 2, 2002 Gary Baldwin, Jr. Sharon Baldwin B June 17, 2002 Gary Baldwin, Jr. Sharon Baldwin C June 19, 2002 Gary Baldwin, Jr. Sharon Baldwin SUBJECT MATTER Notification of death, intestacy, Raising of estate and statutory Distribution. Nationwide tender of $100,000 policy limit Notice of tender of UIM policy limit D July 10, 2002 Gary Baldwin, Jr. Copy of Petition for Approval of Settlement offer, interim distribution sheet, affidavit of consent, consent of Commonwealth. to percentage of inheritance tax for survival action. E July 19, 2002 Received Department of Revenue letter Approving the division between the Survival Action. and the Wrongful Death action as eighty percent (80%) Wrongful Death and twenty (20%) Survival Action F July 29, 2002 Tracy Donmoyer Cover letter to Westfield Group Adjuster providing executed release to hold in escrow pending court Approval. G July 30, 2002 Linda M. Baldwin Notice of Hearing Gary Baldwin, Jr., And Sharon Baldwin, Department of Revenue and methods of concluding estate. H August 2, 2002 Gary Baldwin, Jr. Notice of Hearing date. Sharon Baldwin I August 2, 2002 Gary Baldwin, Jr. Certificates of Mailing Postal Form Sharon Baldwin 3817 J Westfield Group (formerly Old Guard Insurance Company) policy with Declaration sheet -One hundred Thousand ($100,000.00) dollar UIM Coverage. ;Respectfully submitted, KNAUER & ASSOCIATES, L.S.C. (~ t` c 'David W. Knaue , squire Attorney for Plaintiff Attorney I.D. No. 21582 4.11-A East Main Street Mechanicsburg, PA 17055 Date: August 19, 2002 (717) 795-7790 Knauer & Associates, I,SC Attorneys-at Law 411A. East Main Street, Mechanicsburg, PA 17055 Telephone: (?17) 795-7790 L>avid W. Knauer Fax: (717) 795-7793 Email: knauer@earlv.com May 2, 2002 Gary Baldwin, Jr. 803 Royal Crest Dr. Martinsburg, WV 25401 Sharon Baldwin 211 East Washington St. Hagerstown, MD 21740 RE: Baldwin Estate Dear children: Mrs. Linda M. Baldwin has opened the estate for your father and retained our office to prosecute a civil claim against the Defendant who caused his death and your loss. Kindly accept my condolences on the loss of your father. Your father did not have a will. The technical names for people dying without a will are that your father's estate is an intestate. If he had had a will he would have died testate. Because your father did not have a will, the law of the Commonwealth of Pennsylvania determines how his estate will be divided among you and his widow, Linda Baldwin. Mrs. Baldwin is entitled to one half of your father's estate. As you share the same percentages together, so to, you will share the same percentage of costs. The only exception from the foregoing is that Mrs. Baldwin as the administratix of your father's estate is entitled to take an additional 5% of the estate for serving as the administratrix of his estate. Each of you will have equal shares of the remaining half of his estate. To date, the largest expense has been the funeral bill that totaled $8,061.00. My office's Contingent Fee Agreement is thirty three percent of the amount of any recovery. I have learned that the individual who killed your father has $100,000 of automobile insurance that would apply to his loss. Your father also had $100,000 of underinsured insurance (UIM) to compensate the estate in the event that the loss to his estate exceeded the $100,000 of insurance. If you have any questions, please do not hesitate to contact me. Thank you. Very ly yours, ~--~~- David Val. Knauer ' DWK: bm Company\Baldwin\OS-02-02\ltr Knauer & Associates, I,SC Attorneys-at-Law 411A. East Main Street, Mechanicsburg, PA 17055 Telephone: (717) 795.7790 )/~avid W. Knauer Fax: (717) 795-7793 Email: knauer@early.com June 17, 2002 Gary Baldwin, Jr. 803 Royal Crest Dr. Martinsburg, WV 25401 Sharon Baldwin 211 East Washington St. Hagerstown, MD 21740 RE: Baldwin Estate Nationwide Insurance Company has agreed to pay $100,000 to settle your father's claim against its policyholder Matthew Kernan. The $100,000 is the policy limit Nationwide had in force for Mr. Kernan. The adjuster for your father's Uninsured/Underinsured coverage is out of the office on vacation but informed me prior to leaving that she anticipated making a decision with respect to offering a given amount of money or the policy limit on his policy at the end of June or early July. Nationwide has requested your Social Security Numbers and your date of birth. After deduction of our fee and any outstanding costs, each of you will receive twenty five percent of the net settlement. Our fee is one third of the settlement amount. Nationwide also requested me to determine if you would be interested in a structured settlement. A structured settlement provides you less money now and more money over a longer period of years. In effect it is an annuity. Nationwide requested me to provide you with information concerning a structured settlement and I will send that to you after they provide it to me. If you have any questions, please call. DWK: bm Company~B aldwin\06-17 -02 Very truly yours, _ ~// ~~ - ~l David VJ'. Knauer Knauer & Associates, I,SC Attorneys-at-Law 411A. East Main Street, Mechanicsburg, PA 17055 Telephone: (717) 795-7790 David W. Knauer Fax: (71?) 795-7793 Email: knauer@early.com June 19, 2002 Gary Baldwin, Jr. 803 Royal Crest Dr. Martinsburg, WV 25401 Sharon Baldwin 211 East Washington St. Hagerstown, MD 21740 RE: Baldwin Estate Dear Ms. Baldwin and Mr. Baldwin: This afternoon, Westfield Group, the automobile insurer of your father has tendered their Underinsured Policy Limit of $100,000. Consequently, the total automobile insurance for your father has been tendered. There are no further funds to collect. As with the settlement Nationwide tendered to your father's estate, the $100,000 will be divided with his widow receiving $50,000 and each of you receiving $25,000. The gross total money Mrs. Baldwin will receive through the settlement of your father's claims will be $100,000. The gross total money each of you will .receive is $50,000. The net settlement will be reduced by your proportionate share of the costs of the action and the estate. Please provide me with your Social Security Numbers as each insurance company has requested them. If you have any questions, please do not hesitate to contact me. Very t~ly yours, c e~/' c ~,~ David W. Knauer DWK: bm Company\Baldwin\06-14-02\ltr EXH~BtT, ~: _ r fi~ ~~,~~ r= _, Knauer & Associates, LSC Attorneys-at Law 411A. East Main Street, Mechanicsburg, PA 170:15 Telephone: (717) ?95-7790 David W. Knauer Fax: (71?) 795-7793 Email: knauer@early.com July 10, 2002 Gary Baldwin, Jr. 803 Royal Crest Dr. Martinsburg, WV 25401 Sharon Baldwin 211 East Washington St. Hagerstown, MD 21740 RE: Baldwin Estate Dear Ms. Baldwin and Mr. Baldwin: Please find enclosed a copy of the Petition for the Approval of Settlement Offer with two proposed Orders attached, the Distribution Sheet (INTERIM), an Affidavit of Consent for each of you to sign, a Consent of the Commonwealth of Pennsylvania for division of the settlement between a Survival Action Claim and a Wrongful Death Action Claim and a copy of the documents supporting the Distribution Sheet (INTERIM). If an insurance company wishes to have a court approval for a settlement dealing with a death claim, they have the right to do so. Your father's and Linda's insurance company, the Westfield Group, requested court approval. Nationwide Assurance Company, Matthew Kernan's insurer did not request court approval. Consequently, I have prepared and our office will file the petition enclosed. The distinction between a Survival Action and a Wrongful Death Action is solely an inheritance tax issue. A Survival Action is taxable under the inheritance tax and a Wrongful Death Action is not taxable. The Inheritance Tax Division has the right to approve or object to how a settlement is divided. My letter to the Inheritance Tax Division proposes an eighty (80%) percent attribution to the Wrongful Death Action and a twenty (20%) percent to the Survival Action. The state may or may not accept an 80/20 division but that is a starting point for a negotiation of that issue. :[ will attempt to bargain the best settlement for all of you. The Distribution Sheet (INTERIM) deals with the $100,000 we received from Nationwide Assurance; the company that insured Matthew Kernan, the man that killed your father. Out of the $100,000 Nationwide paid, we paid fees and costs advanced. My fee is under our Contingent Fee Agreement is a one third fee of money recovered, under the inheritance law the administratrix or executrix is entitled to a five (5'%) percent fee for their work in handling the affairs of the estate. The difference between an admiristratrix and an executrix is that if the person who died had a will they are called an executrix and if they did not have a will then they are called an administratrix. The: bills Linda paid are the final bills that your father had and they include his funeral costs ;and payment on credit cards that he owned when he died. He and Linda had one joint credit card account and we took half of that bill as his responsibility. He also had a separate account in his name only. Our office had litigation related expenses and estate costs we advanced that have been reimbursed. After deduction of those costs and expenses the net remainder of the $100,000 settlement is $ 47, 992.76. We have opened an interest bearing escrow account using the Employer Identification Number (EII~ of your father's estate and deposited that amount in the account. As soon as we receive the court approval and the $11J0,0000 from the Westfield Group we will be in the position to distribute the funds. If the Court approves the Westfield Group settlement of fifty (50%) percent to Linda and fifty (50%) to be divided between both of you in equal shares, then we will be in a position to pay all bills and charges and distribute the net balance to the three of you. After we receive the $100,000 form the Westfield Group, the deductions will be for our contingent fee, Linda's fee for administering the estate and any unpaid minor bills. Three will be an income taxes (Federal, State and Local) for your father's estate to pay because he died in March of 2002. However, I do not anticipate that those taxes will be large. There is s separate charge for our office for administering the estate. I do not expect that will be a major expense. The final major item is the inheritance tax that will be based on the portion of the estate credited to a Survival Action Claim. Until I receive the response from the Inheritance Tax Division, I cannot give you a better estimate. When you receive the net settlement, there are no income taxes to pay on that amount. I recognize that I have given you a large amount of legal issues and tax issues. If you have any questions, I will be happy to answer them. Also, if you wish, you can consult with an attorney of your choice. If you do that and the other attorney would have any questions, I would be happy to answer any questions that might arise. As to when we will be able to distribute the net funds of the estate, that will depend on when we receive the court's approval of the settlement and how soon after the approval Westfield delivers the check to us. I will be out of the office on vacation until July 22, 2002. By the time I return to the office, I anticipate that we will have either a hearing date from the Court or the other proposed order. Please sign and return the Consent Forms at your earliest convenience. Thank you. Ve ly yours, _~~C~ David W. Knauer DWK: bm Enclosure CC: Mrs. Baldwin Company\Baldwin\07-10-02\ltr COMMONWEALTH OF PENNSYLVANIA- • • - •• - - - 7/19/2002 David W Knauer, Esquire Knauer & Associates 411A East Main Street Mechanicsburg, Pa 17055 DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPARTMENT 280601 HARRISBURG, PA 17128-0601 Telephone 717-783-0972 Re: Estate of Gary L Baldwin File Number: 2102-0408 Court Number: Cumberland-Orphans-21-02-0408 2002 Dear Mr. Knauer: The Department of Revenue has received the Petition for Approval of Settlement Claim to be filed on behalf of the above-referenced Estate in regard to a wrongful death and survival action. It has been forwarded to this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to settle the actions. Pursuant to the Petition, the 54 year old decedent died as a result of a motor vehicle accident. Decedent is survived by the decedent's spouse and two adult children from a prior marriage. Please be advised that, based upon these facts and for inheritance tax purposes only, this Department has no objection to the proposed allocation of the gross proceeds of this action, $ 80,000.00 to the wrongful death claim and $ 20,000.00 to the survival claim Proceeds of a survival action are an asset included in the decedent's estate and are subject to the imposition of Pennsylvania inheritance tax. 42 Pa.C.S.A. §8302; 72 P.S. §§9106, 9107. Costs and fees must be deducted in the same percentages as the proceeds are allocated. In re Estate of Merr rtt~n, 669 A.2d 1059 (Pa. Cmwlth. 1995). I trust that this letter is a sufficient representation of the Department's position on this matter. As the Department has no objections to the Petition, an attorney from the Department of Revenue will not be attending any hearing regarding it. Please contact me if you or the Court has any questions or requires anything additional from this Bureau. Finally, the approval of this allocation is limited to this estate and does not reflect the position that the r~~ra;~Pnr _.,,3~, rake in ~*:~~ ether proposed dis+aibr:tion. of proceeds of 2 wrnngfiil death !survival action. aul Di Inheritance "Cax Division Bureau of Individual Taxes cc: Cumberland County Clerk of Orphans Courts (/ .~-.-z-a .~.,.:--... -_ ..'.. .• -,: -- Knauer & Associates, LSC Attorneys-at Law 411A. East Main Street, Mechanicsburg, PA 17055 Telephone: (717) 795-7790 David W. Knauer Fax: (717) 795.7793 Email: knauer@early.com July 29, 2002 Ms. Tracy Donmoyer Westfield Group P.O. Box 3010 Lancaster, PA 17602 Re: Mrs. Linda Baldwin, individually and as Administratrix of the Estate of Gary Baldwin Dear Ms. Donmoyer: Please find enclosed the fully executed UIM Release that you provided me. This Release is delivered to you to hold in escrow until after. the Court of Common Pleas of Cumberland County decides the pending Petition for the Approval of Settlement Offer and provides its Order and you place the settlement check in the United States Mails postage prepaid addressed to my office. The Court has scheduled the hearing for August 19, 2002. Ve ruly yours, David W. Knauer DWK: bm Enclosure CC: Mrs. Baldwin Company\Baldwin\07-29-02\Itr .. _.. .. _.,_.r._,.. ._ _.~,r .__.._ .. _ - .~.._ _~d . -- -. __,__..,, __ . ._ _. - - -. claim No. iv~~-.~~T-' RELEASE OF UNDERINSITRED/UNINSURED MOTIJRIST CLAIM For and in consideration of the payment to The Estate of Gary L Baldwin and Linda Baldwin, Individually the sum of ($100,000 {$50,000 to the Estate of Gary L. Baldwin and $50,000 to Linda Baldwin, Individually) by Old Guard Insurance a division of Westfield Group the receipt of which is hereby acknowledged, we do hereby fully release and forever discharge said company from any and all claims and causes of action we now have against, said company under the underinsured/uninsured motorist provisior.~ of policy resulting from an accident which occurred on the 16th day of March, 2002 at or around SR 0015, Adams Cty, Freedom T In consideration of this settlement and payment, O].d Guard Insurance a division of Westfield Group does agree to a certain settlement between Nationwide Assurance Company on behalf of :Lts insured Matthew Kernan for liability policy limits of $100,000. Further, O1dGuard Insurance a division of Westfield Group does hereby waive any right of subrogation against Matthew Kernan. And or Nationwide Assurance Company resulting from the payment being made herein. IN WITNESS WHEREOF the part' hereto have hereunto set their hands and seals this ~~' day of 19 or 200 ~T with the i tent'on of being legally bou d hereby. ~. ~ , witness witness state of ~%l~~~ } county of } SS On the day of 2 0 oa, appeared Who executed the foregoing Release of ~~w-~ e~~ ~~ ~ - before me personally Underinsurec~/Uninsured ,.~ ~ voluntarily executed the same . ~ .-. A NOTARIAL SEAL Amy Knauer, Notary Public My t e rm aicsbuEg.f3waagp ;~a+~, of Cum~erlern My Commission Expires Jan. 25, 2005 Notary ~ub~llic Motorist Claim and ~~ acknowledged to me that Knauer & Associates, I,SC Attorneys-at Law 411A. East Main Street, Mechanicsburg, PA 17055 Telephone: (717) 795-7790 David W. Knauer Fax: {? 17) 795-7793 Email: knauer@earl~com July 30, 2002 Linda M. Baldwin 12 E Green Street Mechanicsburg, PA 17055 Gary Baldwin, Jr. 803 Royal Crest Dr. Martinsburg, WV 25401 Sharon Baldwin 211 East Washington St. Hagerstown, MD 21740 RE: Estate Dear Baldwins: Please find enclosed the Notice of Hearing Order. The hearing is open to you and you may wish to attend or participate in the hearing. It is scheduled for August 19, 2002 in Courtroom 3 of the Cumberland County Courthouse at 11:00 a.m. The purpose of the hearing is to obtain the Court's approval of the settlement of the insurance proceeds from your father's estate. There are two ways to conclude your father's estate; one expensive and time consuming and the other Quicker and less costly. The first option is to have a formal proceeding in the Court of Common Pleas of Cumberland County. The chief disadvantages of that procedure is that attorney's fees increase and final distribution is dragged out. The second method is called a Family Agreement. Under that option, the Court does not become involved and you handle it by release documents executed by all of you. As soon as those documents are signed, the proceeds of the estate are then distributed to the three of you after deduction of fees and expenses. I strongly recommend the latter method. If that is satisfactory, please let me know and I can proceed with the paper work. Under Pennsylvania law, the death of Gary, Sr. provided his estate with two types of claims; Survival Action and Wrongful Death Action. The significance of the two for .. you is that the Survival Action is subject to the Inheritance Tax whereas there is no Inheritance Tax on the Wrongful Death Action. In order to make the determination as to what part of an estate is taxable and what part is not taxable, we had. to obtain the consent of the Department of Revenue as to the division. I proposed eighty percent as non- taxable and twenty percent as taxable. The Department of Revenue' s decision only affects Gary, J:r, and Sharon because under the Inheritance Tax Act, transfers between husband and wife are not taxable. However, it will save Gary, Jr. and Sharon the four and one half percent Inheritance Tax on their share of the proceeds. Also, I would request that Sharon execute and return to me the Consent Form I enclosed with my letter of July 10, 2002. I have received the signed form from Gary. If you have any questions, please feel free to call or write. Ve y yours, ~- ~ David W. Knauer DWK: bm Enclosure Company\Baldwinestate\07-30-02\ltr r IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA IN RE: ESTATE OF GARY L. BALDWIN, No. 21-02-0408 2002 Deceased Civil Action Orphans Court ORDER AND NOW, this ; ~ TIC day of July, 2002, upon consideration of the attached Petition for the Approval of Settlement Offer, it is hereby ORDERED and DECREED that the aforesaid petition is hereby set down for hearing on the TH ' I~ day of ~ L1C,LtS 1 , 2002 at I I~~•~~jifi. in Courtroom _~_. By the Court, r, ~.~ A TRUE COPY FROM RECORD In Testimony wh~rof, I hereunto set my hand and the seal of said Court at Carlisle. PA This ,~l day of ,r( '' , ~n('~~ the County -•; .~ - - - - Knauer & Associates, I.SC Attorneys-at Law 411A. East Main Street, Mechanicsburg, PA 17055 Telephone: (717) 795-7790 David W. Knauer Fax: (717) 795-7793 Email: knauer@early.com August 2, 2002 Gary Baldwin, Jr. 803 Royal Crest Dr. Martinsburg, WV 25401 Sharon Baldwin 211 East Washington St. Hagerstown, MD 21740 RE: Estate Dear Gary and Sharon: Please find enclosed a hearing notice on the Petition of Linda L. Baldwin, Administratrix of the Estate of Gary L. Baldwin notifying you of the August 19, 2002 11:00 a.m. hearing before the Honorable George E. Hoffer. The purpose of the hearing is to obtain court approval of the settlement offer of the Westfield Group made to settle the claims of your father's estate and the personal injuries of Linda L. Baldwin. The Westfield Group had an Underinsured Policy limit of $100,000 per accident. Unlike most insurance companies that have the same type of coverage for each person, the Westfield Group's policy did not provide for each person but only for a total settlement of all parties. Consequently, the Court will take testimony and make a decision on whether the proposed division of the Westfield Group's $100,000 will be divided equally between your father's estate and Linda L. Baldwin for her individual claims for losses she suffered in the accident. If the Court approves the settlement as proposed $50,000 will be for the estate. After payment of costs and expenses, the division of that money will be 50% to Linda L. Baldwin and 50% to be divided equally between the two of you. Also, I enclose for Sharon's execution another Affidavit of Sharon Baldwin that I enclosed with my letter of July 10, 2002 and another self-addressed postage prepaid envelope for Sharon to return to me. Gary has already returned to me his signed Affidavit. If either of you have any questions, please do not hesitate to contact me. Very ly yours, .. ~" David W. Knauer DWK: bm Enclosure CC: Linda Baldwin Company\Baldwin\08-02-02\ltr t. .. ~ a'~ .. - .. U.S. POSTAL SERVICE CERTIFICATE OF MAILIN ~~II- MAY BE USED FOR DOMESTIC AND INTERNATIONAL MAIL, DO `~'~~v. c PROVIDE FOR INSURANCE-POSTMASTER ~ ~ Received From: ~ ~ ~ ~ ~M `~' ' _~ Knauer $~ ASSC1Cid.t6S 1.e7~Tt, */N~- 417 A E. Main Street ~ / 055-~ °~'~ z c n n c o~ 9GC7 9 N T OOJ?~ (JIO ~• -U WCy 00 N ~ ~ ._ ~ m =o x PS Form 3817, Mar. 1989 } ",.~~~ ~ mot'.` + ~, ~ ,.: '. a• ,, ~ 1 ' .•S '- i ar ~:,; ~~tt: s ~ r r a+ t •r ._j. j r P ;~. f"'.,r,~> ~=.. ' ~.=' .++ 1~ tLa ~ •t~jr ./ ~ x ..w J- r rs:a rr~l. ~ Ya f ,u,..s ~ •~ r ~~Y •r~ 1~~-y.P ~i'~~Sx .. ~-J +.:F, i s +.1yR I~ - : ~ .,3. ~~ i >.~... dt 2 .~,, ~~+- j r~ : ti a ~ ~' > a ~/• • -"+. ~ ` S ' y~.% 1.:Nr..+a a ~_. :~. .. 4 • 3 ••r . ,.~ +,>Yr } .. ~ ~~i~ mss,..!,- + ~' - ~3'.+,~!+°..+,''"..s, s 3;a.L "=c ^> a. ^f / ~• tl,: t .;a t ~1~,ti1'"•.•~+~.+•" :~L~''~F,~+'' r ^• MAY BE USED FOR DOMESTIC AND INTERNATIONAL MAIL, DOES NOT a e PROVIDE FOR INSURANCE-POSTMASTER c -. , , a Received From: r`c' '' i ••, rid a' s Knauer & RsSc ~f-Z~~r+eee-~ 411 A E. Main m o C~C (~ C o~ G7 9 N QH CNOf~~~ NW -Zi• N~CN OO N CCD D d r7 C"7 m =o x ~~~~ OLD GUARD Old Guard IlvSURANCE COMPANY INSURANCE GROVP 201 East Oregon Rd P.O. Box 3010 Lancaster PA 17604 (717) 569-5361 THIS POLICY IS NON-ASSESSABLE PART B DECLARATION PAGE PAGE 01 OF 07 PERSONAL AUTOMOBILE STANDARD ~" - Renewal Declarations EFFECTIVE 01/13/02 POLJCY?lUNBER'I ~~ ..POLICY PERIOD TO 1010029604 01/13/02 07/13/02 12:01 AM STANDARD TIME NAMED 1NSUREDiAND ADDRESS AGENT. 00430_` SUB:.. LINDA M BALDWIN GARY L BALDWIN 12 E GREEN ST IdECHANICSBURG PA 17055 HULSE ASSOCIATES INC 5 E MAIN ST MECHANICSBURG PA 17055 PHONE: (717) 766-7621 Batch Renewal PREMIUM SUMMARY BASIC ATTACHED SCHEDULED POLICY TOTAL COVERAGES ENDORSEMENTS PROPERTY FEES/TAXES POLICY PREMIUM PREMIUM PREMIUM PREMIUM $412.00 $0.00 $412.00 ---------------- VEHICLES COVERED ------------ ----- VEH YR MAKE MODEL IDENTIFICATION TYPE SYM ST TER USE CLASS 1 94 SATII SLl 1G8ZH5597RZ354475 PP 05 PA 027 P 800120 3 97 FORD T BIRD LX 1FALP6244VH103769 PP 10 PA 027 P 800120 ------------------- COVERAGES--------- -----•------- Insurance is provided where a premium is shown for the coverage COVERAGE PREMIUMS VEH 1 VEH 3 SINGLE LIMIT LIABILITY $68.00 $68.00 $100,000 Each Accident Full Tort UNINSURED MOTORIST COVERAGE $6.00 $6.00 $100,000 Each Accident Non-Stacked UNDERINSURED MOTORIST COVERAGE $14.00 $14.00 $100,000 Each Accident Non-Stacked ADDED FIRST PARTY BENEFITS $20.00 $20.00 Additional Med Expenses $100,000 WORK LOSS BENEFITS IIP TO $1,000 PER $7.00 $7.00 Month to a Maximum of $5,000 FUNERAL EXPENSES $1,500 $2.00 $2.00 TOWING & LABOR - $75 PER OCCURRENCE $5.00 $5.00 INCREASED LIMITS-TRANSPORTATION EXP $5.00 Coverage up to $30 per Day to a Maximum of $900 EXHIBIT ~ -- -j:, .° Continued on Next Page... ~ Insured Copy ~ OLD GUARD PART B DECLARATION PASSE INSURANCE COMPANY PAGE 02 OF 07 Old Guard 201 East Oregon Rd P.O. Box 3010 PERSONAL AUTOMOBILE INSURANCE GROUP Lancaster PA 17604 STANDARD - - -~ (717)569-5361 Renewa I Dec I arat i ons THIS POLICY IS NON-ASSESSABLE EFFECTIVE 01/13/02 DB .. . '' DOUC1fNUWIBEq:'.s: FR Tt{ YO{JCY PERIOD <: ~ ,; ...; ....... 'r 1010029604 01/13/02 07/13/02 12:01 AM STANDARD TIME >Neni>Fn 1NSC]RFn oND ODDRESS AGENT: x043.0 ! - SUB: LINDA M BALDWIN GARY L BALDWIN 12 E GREEN ST MECHANICSBURG PA 17055 PHONE: (717) 766-7621 HULSE ASSOCIATES INC 5 E MAIN ST MECHANICSBURG PA 17055 ------------------- COVERAGES--------------------- Insurance is provided where a premium is shown for the coverage COVERAGE PREMIUMS VEH 1 VEH 3 Collision VEH 1 VEH 3 DEDUCTIBLES - $200 $200 $49.00 $76.00 LIMITS - ACTUAL CASH VALUE LESS DEDUCTIBLE other Than Collision VEH 1 VEH 3 DEDUCTIBLES - $100 $100 $14.00 $24.00 LIMITS - ACTIIAL CASH VALUE LESS DEDUCTIBLE TOTAL PREMIUM PER VEHICLE $185.00 $227.00 THIS POLICY PROVIDES COLLISION COVERAGE FOR RENTAL VEHICLES SUBJECT TO A DEDIIGTIBLE AND OTHER LIMITATIONS IN THE POLICY. --------------- DRIVER DR# NAME 1 LINDA M BALDWIN DATE OF BIRTH SEX MAR.STS. 06/02/51 F M DR# NAME 2 GARY L BALDWIN DATE OF BIRTH SEX MAR.STS. 04/27/47 M M INFORMATION LICENSE NUMBER 15702269 VEH# PRIN/OCC DT GS POINTS 1 P 0 LICENSE NUMBER 21948435 VEH# PRINlOCC DT GS POINTS 3 P 0 --- ------ POLICY FORMS AND ENDORSEMENTS --- ----- -- NUMBER EDITION UNIT PP 03 03 04-86 Towing & Labor Coverage VEH 1 PP 03 05 08-86 Loss Payable Clause VEH 1 PP 03 09 06-98 Single Liability Limits VEH 1 PP 04 16 06-98 Single UIM Cov - PA Non-Stacked VEH 1 PP 04 17 12-98 UIM Coverage - PA Non-Stacked VEH 1 PP 04 20 06-98 Single UM Coverage - PA Non-Stacked VEH 1 PP 04 2i 12-98 UM Coverage - PA Non-Stacked VEH 1 PP 05 51 06-94 First Party Benefit Coverage - PA VEH 1 PP 13 O1 12-99 Coverage for Damage to Auto Exclusion VEH 1 PP 03 02 06-98 Optional Transportation Expense Cover VEH 3 10 PREMIUM Continued on Next Page... Insured Copy • OLD GUARD PART B DECLARATION PAGE INSURANCE COMPANY PAGE 03 OF 07 Old Guard 201 East Oregon Rd P.O. Box 3010 PERSONAL AUTOMOBILE INSURANCE GROUP Lancaster PA 17604 STANDARD ~ - - (717)569-5361 Renewa ( Dec I arat i ons THIS POLICY IS NON-ASSESSABLE EFFECTIVE 01/13/02 DH ~~ ,.e..oucr P~a~on To 'I' POLICY NtltABER ; 1010029604 01/13/02 07/13/02 12:01 AM STANDARD TIME . NAMED:i1NSE1RED AND ADDRESS AGENT: 0:0430 SUB: LINDA M BALDWIN GARY L BALDWIN 12 E GREEN ST MECHANICSBURG PA 17055 HULSE ASSOCIATES INC 5 E 1~1AIN ST MECHANICSBUF:G PA 17055 PHONE: (717) 766-7621 --- ------ POLICY FORMS AND ENDORSEMENT~> --- ------- NUMBER EDITION UNIT PP 03 03 04-86 Towing & Labor Coverage VEH 3 PP 03 05 OS-86 Loss Payable Clause VEH 3 PP 03 09 06-98 Single Liability Limits VEH 3 PP 04 16 06-98 Single UIM Cov - PA Non-Stacked VEH 3 PP 04 17 12-98 IIIM Coverage - PA Non-Stacked VEH 3 PP 04 20 06-98 Single UM Coverage - PA Non-Stacked VEH 3 PP 04 21 12-98 DM Coverage - PA Non-Stacked VEH 3 PP 05 51 06-94 First Party Benefit Coverage - PA VEH 3 PP 13 01 12-99 Coverage for Damage to Auto Exclusion VEH 3 AT 090 0 03-92~ PA Surcharge Disclosure Statement Policy AT 10 10 09-97 Old Guard Ins Group Amendatory Endors Policy IL 09 10 01-81 Pennsylvania Notice Policy PP 00 O1 06-98 Personal Auto Policy Policy PP O1 51 06-98 Amendment of Policy Provisions - PA Policy DISCOUNTS/SURCHARGES 10 PREMIUM The following discounts/surcharges have been applied to your policy premiums: Multi Policy Discount Safe Driver Discount Anti-Lock Brake Discount Passive Restraint Discount -------------- ADDITIONAL INTERESTS --------------- UNIT Loss Payee 1 VEH 1 DAUPHIN DPST BK AND TRUST PO BOX 4800 HARRISBURG PA 17108 Loss Payee 2 VEH 3 DAIIPHIN DPST BK AND TRUST CO PO BOX 4900 HARRISBURG PA 17111 Continued on Next Page... Insured Copy Old Guard WSURANCE GROUP THIS POLICY IS NON-ABBE PD '' POEiCY NtfMBER 3 > ;)<1 . 1010029604 01/13/0 LINDA M BALDWIN GARY L BALDWIN 12 E GREEN ST MECHANICSBURG PA 17055 OLD GUARD PART B DECLARATION PAGE INSURANCE COMPANY PAGE 04 OF 07 201 East Oregon Rd P.O. Box 3010 PERSONAL AUTOMOB I L E Lancaster PA 17604 STANDARD - - (717)569-5361 Renewa I Dec I arat i ons SSABLE EFFECTIVE 01/13/02 DB L3CY PERIOD, : Tp 2 07/13/02 12:01 AM STANDARD TIME ;S AGENT:.. x0430 '~? > SUB: HULSE ASSOCIATES INC 5 E MAIN ST MECHANICSBURG PA 17055 PHONE: (717) 766-7621 -------------- ADDITIONAL INTERESTS -------------- UNIT 10 THIS REPLACES ALL PREVIOUSLY ISSUED POLICY DECLARATIONS, IF ANY. THIS POLICY APPLIES ONLY TO ACCIDENTS, OCCURRENCES, OR LOSSES WHICH HAPPEN DURING THE POLICY PERIOD SHOWN ABOVE. AGENCY AT MECHANICSBURG PA ~~~ ~ DATE 12/13/01 Insured Copy AUTHORIZED COUNTERSIGNATURES i PAGE 05 OF 07 Insurance Company Personal Auto Declarations Old Guard P.o. Box 3010, 2929 Lititz Pike o cy um r INSURANCEGROUP Lancaster, Pa.1760~ STANDARDJRENEWAL WAL 1010029604 NOTICE OF TORT OPTIONS A. "Limited Tort" Option --This form of insurance limits your right and the rights of members of your household to seek financial compensation for injuries caused by other drivers. Under this form of insurance, you and other household members covered under this policy may seek recovery for all medical and other out-of-pocket ex- penses, but not for pain and suffering or other nonmonetary damages unless the injuries suffered fall within the definition of "serious injury," as set forth in the policy, or unless one of several other exceptions noted in the policy applies. B. "Full Tort" Option -- This form of insurance allows you to maintain an unrestricted right for yourself and other members of your household to seek financial compensation for injuries caused by other drivers. Under this form of insurance, you and other household members covered under this policy may seek recovery for all medical and other out-of-pocket expenses and may also seek financial compensation far pain and suffering or other non- monetary damages as a result of injuries caused by other drivers. If you wish to change the tort option that currently applies to your policy, you must notify your agent, broker or com- pany and request and complete the appropriate form. PENNSYLVANIA FRAUD STATEMENT ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COM- PANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND CIVIL PENALTIES. ~~~~ ~,t .~. ~~~~ rrroFS~~os~ AUTHORIZED COUNTERSIGNATURE i PAGE 06 OF 07 Personal Auto Declarations STANDARD~RENEWAL WAL ~ 1010029604 NOTICE OF ADDITIONAL PREMIUM DISCOUNTS Insurance companies operating in the Commonwealth of Pennsylvania are required by law to provide premium dis- counts for motor vehicles: (1) Equipped with passive restraint devices. Discounts shall not be less than 15% for passive seat belts, 20% for one airbag on the operator's side of the vehicle and 30% for two airbags. These discounts are to be applied to the first party benefits coverage. (2) Equipped with a passive anti-theft device. Any item or system installed in an automobile which is activated automatically when the operator turns the ignition key to the off position and which is designed to prevent un- authorized use, as prescribed by regulations of the commissioner wilt be eligible for a discount that shall be ap- plied to comprehensive coverage, and shall not be less than 10%. Additionally, insurance companies are required to provide a premium discount for each motor vehicle on a policy under which all named insureds are 55 years of age or older and have successfully completed a motor vehicle driver improvement course meeting the standards of the Department of Transportation. This discount shall apply to all coverages for all policy periods beginning within the three-year period immediately following the successful comple- tion of the course, and shall be approved by the commissioner as part of the insurer's rate filing, provided that such discount shall not be less than 5%. Your policy may already reflect these discounts, so you should check your policy declarations. If you have questions, or believe you qualify for one or more of these discounts, and are not already receiving the appropriate credit, please notify your agent or company for additional information. .~J . ! .~-~ `- ~~~ ~ NAPD(7A5) AUTHORIZED COUNTERSIGNATURE Insurance Company Old Guard P.o. Box 3010, 2929 Lititz Pike INSURANCE GROUP Lancaster, Pa. 17064 PAGE 07 OF 07 Insurance Company Personal Auto Declarations P.O. Box 3010 2929 Lititz Pike o cy um er Old Guard STANDARDJRENEWAL WAL t 0~ oo2s6oa INSURANCE GROUP Lancaster, Pa. 17604 MINIMUM MOTOR VEHICLE INSURANCE LIMITS The laws of the Commonwealth of Pennsylvania, as enacted by the General Assembly, only .require that you pur- chase liability and first-party medical benefit coverages. Any additional coverage or coverages iri excess of the limits required by law are provided only at your request as enhancements to basic coverages. Under Act 6 of 1990 all insurers are required to advise policyholders of the minimum limits of coverage available. The coverages indicated below represent the minimum coverages you must maintain. The premiums displayed are the premiums for these minimum coverages. The premiums indicated are based on our file information and may be sub- ject to later adjustment depending on vehicle use, driver classification and other rating factors. Premiums Auto 1 'Auto 2 Auto 3 Auto 4 Single Limit Liability $35,000 Ea. Accident Added First Party Benefits Medical Expenses $5,000 55 I I 55 10 I I 10 .Total Premium ~ 13 0 THIS PAGE IS FOR COVERAGE AND PREMIUM COMPARISONS ONLY AND DOES NOT CONSTITUTE ADDITIONAL OR ACTUAL COVERAGE PROVIDED UNDER THIS POLICY. N.MVIL {7.95) v m~ ~L '> ca O V $« aw O i m V ~ ~ C .a m R . ~a '- O -.. c~ m T3 a3 0 ~~ •3 O N ~ t *+ mw ~~ m~ :~ N ,r ` -:z :~ d :.~r:. s{t'~a.V) . _ ..'--~~ m ~ y ~ cc~ ~` m~ ~ C C ~ ts! ` cVII ~ ~ ~ ~ c m> ~ O y O •~ ~_ .`~ c O m Q N m ~~ 0 h ~ e~ ~a c 0 '~ N Z W M v >' O .O m _ `~ r a (~ NCB ~ A 7 ~ W ~ a ~ N ~ ~ ~ ~ ~ r .+ • ~ o ~ ' o' a E O- ( ~ S ~ ~ •-- Er Q O to .. ~ ~ '~ ~ > ~ N t O ... A a C \ a~ c) ~` ~ O ,~- Ltl ~ M r ~ ~ ~~}. ~1 L= ~ _ C ~ ~ ' ~ -~ .-, .' ~' ~i ~ i. i~ to ~ ~ O ...~~ ~_ ~ U T_ '.: T,i '. ~ ~ ^ ^ ,.fir ,rr' [ ] ~'~+ v Q~ ~ S - z H '~ Q N_ U Q. • . ~ dA ~"+ ~ ~+_' .. (y ~ v- ~ O .~ .~ C ~ ~ ~ f- ~ ~ r.+ ~ ~ U E- a > ~ . 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H r Q S 8 OLD GUARD PART B DECLARATION PAGE INSURANCE COMPANY PAGE Ot OF 04 Old Guard 201 East Oregon Rd P.O. Box 3010 PERSONAL AU_TOMOB I LE _ INSURANCE GROUP Lancaster PA 17604 STANDARD - - (717)569-5361 Amended Dec I arat i ons THIS POLICY IS NON-ASSESSABLE EFFECTIVE 12/01/01 DB -. POLICY PERI00 POLICY NUQBER fROM 70 1010029604 07/13/01 01/13/02 12:01 AM STANDARD TIME nte~uf=n INSURED AND oDDRESS AGENT:' 00430 SUB: ___ LINDA M BALDWIN GP.RY L BALDWIIQ 12 E GREEN ST MECHANICSBURG PA 17055 HULSE ASSOCIATES II4C 5 E MAIN ST MECHANICSBURG PA 17055 PHONE: (717) 76Ei-7621 ---------------- POLICY REVISIONS ---------------- Loss Payee revised Vehicle 3 revised Agent requested this change. PREMIUM SUMMARY BASIC ATTACHED SCHEDULED POLICY TOTAL COVERAGES ENDORSEMENTS PROPERTY FEES/TAXES POLICY PREMIUM PREMIUM PREMIUM PREMIUM $462.00 $0.00 $462.00 10 CHANGE IN PREMIUM $11.00 ---------------- VEHICLES COVERED ---------------- VEH YR MAKE MODEL IDENTIFICATION TYPE SYM ST TER USE CLASS 1 94 SATII SL1 1G8ZH5597RZ354475 PP OS PA 027 P 800120 3 02 KIA SDNA L%/E% KNDIIP131826211440 PP 12 PA 027 P 800120 ------------------- COVERAGES----------------~----- Insurance is provided where a premium is shown for the coverage COVERAGE PREMIUMS VEH 1 VEH 3 SINGLE LIMIT LIABILITY $68.00 $68.00 $100,000 Each Accident Full Tort IININSIIRED MOTORIST COVERAGE $100,000 Each Accident Non-Stacked IINDERINSIIRED MOTORIST COVERAGE $100,000 Each Accident Non-Stacked ADDED FIRST PARTY BENEFITS Additional Med Expenses $100,000 WORK LOSS BENEFITS IIP TO $1,000 PER Month to a Maximum of $5,000 FIINERAL EXPENSES $1,500 TOWING & LABOR - $75 PER OCCURRENCE $6.00 $6.00 $14.00 $14.00 $21.00 $21.00 $7.00 $7.00 $2.00 $2.00 $5.00 $5.00 Continued on Next Page... rns„~a copy OLD GUARD PART B DECLARATION PAGE INSURANCE COMPANY PAGE 02 OF oa Old Guard 201 East Oregon Rd P.O. Box 3010 PERSONAL AU.TOMOB I L E INSURANCE GROUP Lancaster PA 17604 STANDARD (717)569-5361 Amended Declarations THIS POLICY IS NON-ASSESSABLE EFFECTIVE 12/01/01 DB POLICY NUMBER . ; , ;: ~ M :i POl1CY >'ERlOD :., TO ; 1010029604 07/13/01 01/13/02 12:01 AM STANDARD TIME NAMED INSURED AND ADDRESS AGENT: 00430 SUB: LINDA M BALDWIN GARY L BALDW I I4 12 E GREEN ST 1dECHANICSBURG PF. 17055 SEX MAR.STS F M PHONE: (717) 766-7621 ------------------- COVERAGES--------------------- Insurance is provided where a premium is shown for the coverage COVERAGE PREMIUMS INCREASED LIMITS-TRANSPORTATION EXP $5.00 Coverage up to $30 per Day to a Maximum of $900 Collision VEH 1 VEH 3 DEDIICTIBLES - $200 $200 $49.00 $110.00 LIMITS - ACTIIAL CASH VALIIE LESS DEDIICTIBLE Other Than Collision VEH 1 VEH 3 DEDIICTIBLES - $100 $100 $14.00 $38.00 LIMITS - ACTIIAL CASH VALIIE LESS DEDIICTIBLE TOTAL PREMIUM PER VEHICLE $186.00 $276.00 THIS POLICY PROVIDES COLLISION COVERAGE FOR RENTAL VEHICLES SIIBJECT TO A DEDIICTIBLE AND OTHER LIMITATIONS IN THE POLICY. --------------- DRIVER INFORMATION DR# NAME 1 LINDA M BALDWIN DATE OF BIRTH 06/02/51 DR# NAME 2 GARY L BALDWIN DATE OF BIRTH 04/27/47 NUMBER EDITION PP 03 03 04-86 PP 03 05 08-86 PP 03 09 06-98 PP 04 16 06-98 PP 04 17 12-98 PP 04 20 06-98 PP 04 21 12-98 SEX MAR.STS M M HULSE ASSOCIATES INC 5 E MAIN ST MECHANICSBURG PA 17055 VEH# 1 VEH# 3 --------------- LICENSE NUMBER 15702269 PRIN/OCC DT GS POINTS p 0 LICENSE NUMBER 21948435 PRIN/OCC DT GS POINTS p 0 ----- POLICY FORMS AND ENDORSEMENTS Towing & Labor Coverage Loss Payable Clause Single Liability Limits Single IIIM Cov - PA Non-Stacked IIIM Coverage - PA Non-Stacked Single IIM Coverage - PA Non-Stacked UM Coverage - PA Non-Stacked UNIT VEH 1 VEH 1 VEH 1 VEH 1 VEH 1 VEH 1 VEH 1 10 PREMIUM Continued on Next Page... Insured Copy - OLD GUARD PART B DECLARATION PAGE INSURANCE COMPANY PAGE 03 OF 04 Old Guard 201 East Oregon Rd P.O. Box 3010 PERSONAL AUT_ _OM_OB 1 LE INSURANCE GROUP 1~ancasterPA 17604 STANDARD (717)569-5361 Amended Dec I arat i ons THIS POLICY IS NON-ASSESSABLE EFFECTIVE 12/01/01 DB POLICY PERIOD - TO .POLICY NUMBER FROM - 1010029604 07/13/01 01/13/02 12:01 AM STANDARD TIME NAMED INSURED-AND ADDRESS AGENT: ' 00430 SUB: L I IdDA M BALDW I N GARY L BALDW I IJ 12 E GREEN ST MECHAIQICSBURG PA 17055 HULSE ASSOCIATES INC 5 E MAIN ST MECHANICSBURG PA 17055 PHONE: (717) 766-7621 --- ------ POLICY FORMS AND ENDORSEMENTS --- ------- NUMBER EDITION UNIT PP 05 51 06-94 First Party Benefit Coverage - PA VEH 1 PP 13 O1 12-99 Coverage for Damage to Auto Exclusion VEH 1 PP 03 02 06-98 Optional Transportation Expense Cover VEH 3 PP 03 03 04-86 Towing & Labor Coverage VEH 3 PP 03 05 08-86 Loss Payable Clause VEH 3 PP 03 09 06-98 Single Liability Limits VEH 3 PP 04 16 06-98 Single IIIM Cov - PA Non-Stacked VEH 3 PP 04 17 12-98 IIIM Coverage - PA Non-Stacked VEH 3 PP 04 20 06-98 Single IIM Coverage - PA Non-Stacked VEH 3 PP 04 21 12-98 ~IIM Coverage - PA Non-Stacked VEH 3 PP 05 51 06-94 First Party Benefit Coverage - PA VEH 3 PP 13 O1 12-99 Coverage for Damage to Auto Exclusion VEH 3 AT 090 0 03-92 PA Surcharge Disclosure Statement Policy AT 10 10 09-97 Old Guard Ins Group Amendatory Endors Policy IL 09 10 01-81 Pennsylvania Notice Policy PP 00 01 06-98 Personal Auto Policy Policy PP 01 51 06-98 Amendment of Policy Provisions - PA Policy DISCOUNTS/SURCHARGES 10 PREMIUM The following discounts/surcharges have been applied to your policy premiums: Multi Policy Discount Safe Driver Discount Anti-Lock Brake Discount Passive Restraint Discount -------------- ADDITIONAL INTERESTS -------------- UNIT Loss Payee 1 VEH 1 DAIIPHIN DPST BR AND TRIIST PO BO% 4800 HARRISBIIRG PA 17108 Continued on Next Page... in~,~a cop,• OLD GUARD PART B DECLARATION PAGE INSURANCE COMPANY PAGE o4 OF 04 Old Guard 201 East Oregon Rd P.O. Box 3010 PERSONAL AUILOINOB I L E wsuw~NCe CROUP Lancaster PA 17604 STANDARD (717)569-5361 Amended Dec I arat i ons THIS POLICY IS NON-ASSESSABLE EFFECTIVE 12/01/01 DB POLICY NUMBER _ FAOM';?000Y,PERIOD'.TO' 1010029604 07/13/01 01/13/02 12:01 AM STANDARD TIME rlw~ucn I~ICIIRGn enln ennRf=ss 'AGENT: 00430 - SUB: LINDA M BALDWIIJ HULSE ASSOCIATES INC GARY L BALDWIN 5 E MAIN ST 12 E GREEN ST MECHAI4ICSBURG PA 17055 MECHANICSBURG PA 17055 PHONE: (717) 766-7621 10 -------------- ADDITIONAL INTERESTS -------------- UNIT Loss Payee 2 VEH 3 HUDSON UNITED BANK 1000 MCARTHUR BLVD MAHWAH NJ 07430 THIS REPLACES ALL PREVIOUSLY ISSUED POLICY DECLARATIONS, IF ANY. THIS POLICY APPLIES ONLY TO ACCIDENTS, OCCURRENCES, OR LOSSES WHICH HAPPEN DURING THE POLICY PERIOD SHOWN ABOVE. AGENCY AT MECHANICSBURG PA ~ DATE 01/04/02 j ~ !~~ ~E~~~ ~. Insured Copy AUTHORIZED COUNTERSIGNATURES FlNANCIAL RESPONSIBILITY IDENTIFICATION CARD Old Guard Insurance Company P.O. Box 3010 • Lancaster, A 17604 COMPANY NO. 17 5 5 8 POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE 1010029604 01/13/2002 07/13/2002 ~~ NOT VALID MORE THAN 1 YEAR FROM EFFECTIVE DATE DESCRIPTION OF VEHICLE ~I YEAR MAKEJMODEL IDENTIFICATION NUMBER ~ 02 KIA/SDNA LX/EX K14DUP131826211440 AGENCY~COMPANY ISSUING CARD 'HULSE ASSOCIATES INC .Phone: (717) 766-7621 INSURED: LINDA M BALDWIN GARY L BALDWIN 12 E GREEN ST MECHANIGSBURG PA 17055 24Hour Claim Service 1-800-7_32-0050 SEE IMPORTANT INFORMATION ON REVERSE SIDE FINANCIAL RESPONSIBILITY IDENTIFICATION CARD Old Guard Insurance Company P.O. Box 3010 • Lancaster, A 17604 COMPANY N0.17 5 5 8 POLICY NUMBER` ~ EFFECTNE DATE EXPIRATION DATE. 1010029604 01/13/2002 07/13/2002 NOT VALID MORE THAN 1 YEAR FROM EFFECTIVE DATE DESCRIPTION OF VEHICLE YEAR MAKE(MODEL IDENTIFICATION NUMBER 02 KIA/SDNA I,X/EX KNDUP131826211440 AGENCY(COMPANY ISSUING CARD HULSE ASSOCIATE'S I]JC Phone: (717) 766-7621 INSURED: LINDA M BALDWIN GARY L BALDWIN 12 E GREEN ST MECHANIGSBURG PA 17055 24-Hour Claim Service 1-800-732-0050 SEE IMPORTANT INFORMATION ON REVERSE SIDE IMPORTANT NOTICE REGARDING YOUR FINANCIAL RESPONSIBILITY IDENTIFICATION CARD Ibis card must be carried frn produedw upon demand. b is su{{sited that you eery this card is the insured vehicle. WAR\II`G: Any owner or registrant of a motor vehicle who drives or ppeermits a motor vehicle to be driven in this State without the required financial responsibility may have his registration suspended or revoked. \OTE: THIS CARD IS REQUIRED WHEIq - (1) You are involved is an auto accident; (2) You arc convicted of a traffic offerue other thaw a pazlang offense that requires a court appearance; (3) You are stopped for violating nay provision of 75 Pa.C.S. (relating to the Vehicle Codc) and requested to produce it by a police officer. You ffitst ptotide a aspy of this card m the Department of Tnasporudoa ahea you request restoradon of yom operating privilege andtrn rcgisaadw pric•i)egc which has btra previws]y wspended m revoked. The Old Guard lasuraaee Company is roquitcd by Pennsylvania law w send you an I.D. card. 7'he card shoal that an iastuwee policy has been issued frn the vehicle(s) dacsbcd xdsfyiag the fmaadal responsibiliry requ'vemcnts of the ]aw, if you ]ore the urd, Bonnet your iasuranee t~ompany m agent for a replaermen~ 71rc LD. card inform don may be used for vehje]e rcgistradon and repladng license plates. If your liability iaauraacc poliq• is not is e}feet, the ID. card is aolwger valid. }•ov arc rcgv'ucd m maiataia fmaadal raponsibiliry oa your veltic]e. It is a{aintt Peaasylvaaia law to six the LD. urd fraudulently such as using the nrd as proof of fiaandal raponsibiliry after the instaana policy is tsrminated PLEASE SEE REVERSE SIDE IMPORTANT NOTICE REGARDING YOUR FINANCIAL RESPONSIBILITY IDENTIFICATIOM CARD , This card ttatst be carried fm produrstm upon demand. It is su{gestrd that you carry Ibis card fa the insured vehicle. WAR'~~L\G: Any owner or registrant of a motor vehicle who drives or ppeelmits a motor vehicle to be driven in this State without the required financial responsibility may have his registration suspended or revoked. 40TE: THIS CARD IS REQUIRED WHEN -- (1) You are involved in an auto accidcny (2) You ate convicted of a traffic offense other than a parking offense that requires a coon appearance; (3) You are stopped for violating any provision of 75 Pa.C.S. (relating to the Vehicle: Code) and requested to produce it by a police officer. You most prm•ide a copy of this wd m the Department of 7ransponadon abea you tegvext ratoradan of your operating privilege and~rn rs{isaadoa privilege ahiclt h~ Dcea preciously suspeadod rn revoked. 7be Old Guard Iasuraaoe Company is required by Pcansyh•ania law to seed you an LD. card. The card shoal that as iasvrance policy bas beta issued for the vchielo(s) ducsibed satisfyia{ the finandal raponsibiliry requireaswu of the La•. If you lox the card, comet your iaswanoe company rn agent for a replacemeaL Tne 1.D. card information may be used frn vehicle rcgisaadoa and replacing lic<nse pLtes. N your liabilin• in tawee polity is not is effect, the LD. card is ao loaga valid. }'ou arc rcyvired m maintain fiaaadal respoasibility an your vehicle It is •{ainst Peaosylvaaia laa• w use the 1.D. card fnvduleatly suc3 a: acing the nrd as proof of fiaandal responsibility aftc the iasmaaa policy is icrmtDatcd. PLEASE SEE REVERSE SIDE FlNANCIAL RESPONSIBILITY IDENTIFICATION CARD Old Guard Insurance Compan~ P.O. Box 3010 • Lancaster, PA 1 604 COMPANY NO. 17 55 8 POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE 1010029604 12/01/2001 01/13/2002 NOT VALID MORE THAN 1 YEAR FROM EFFECTIVE DATE DESCRIPTION OF VEHICLE YEAR MAKE/MODEL IDENTIFICATION NUMBER 02 KIA/SDNA LX/EX KNDUP131826211440 AGENCY/COMPANY ISSUING CARD NULSE P.SSOCIATES INC Phone: (717) 766-7621 INSURED: LINDA M BALDWIN GARY L BALDWIN 12 E GREEN ST MECHANICSBURG PA 17055 FINANCIAL RESPONSIBILITY IDENTIFCATION CARD Old Guard Insurance Compan~- P.O. Box 3010 • Lancaster, PA 1 604 COMPANY N0.17 5 5 8 POLICY NUMBER EFFECTJVE.DATE EXPIRATION DATE . 1010029604 12/01/2001 01/13/2002 NOT VALID MORE THAN 1 YEAR FROM EFFECTNE DATE DESCRIPTION OF VEHICLE YEAR MAKE/MODEL IDENTIFICATION NUMBER 02 KIA/SDNA LX/EX KNDUP131826211440 AGENCY/COMPANY ISSUING CARD NULSE ASSOCIATES INC Phone: (717) 765-7621 INSURED: LINDA M BALDWIN GARY L BALDWIN 12 E GREEN ST MECHANICSBURG PA 17055 24-Hour Claim Service 1-800-732-0050 SEE IMPORTANT INFORMATION ON REVERSE SIDE 24-Hour Claim Service 1-B00-732-0050 SEE IMPORTANT INFORMATION ON REVERSE SIDE IMPORTANT NOTICE REGARDING YOUR FINANCIAL RESPONSIBILITY IDENTIFICATION CARD Ibis card ttatst be coded for produedw vpw demand. h is suggested thu you awry this card is the insured vchialc. WAR'~'L'~'G: Any owner or registrant of a motor vehicle who drives or permits a motor vehiclt to be driven in this State without the required financial responsibility may have his registration suspended or revoked. NOTE: THIS CARD IS REQUIRED WHEN -- (1) You are involved in an auto accident; (2) You are convicted of a traffic offalse other than a pazling offense that requires a court appearance; (3) You are stopped for violating any provision of 7S Pa.C.S. (relating to the Vehicle Code) and requested to produce it by a police officer. You >mrSi prosbdc • Dopy of this Lard m the Dcpuwrat of Traasponadw rhea you rcgvesi restoradoa of your operating pdwTege and/or mgisiradw prittilege ahieh has bun pm4ous]y suspended or re.•okcd. The Old Guard lnstaaau Cosat+any is required by Pennsylvania lav m scud yw an 1D. card. The card shows that an insvranu pour hu been issued for the vehidds) dumbed satisfjiag the finaadal tesponsibilit)'rcquiremcats of the laa•• if you lose the cud, ewtau your insunaa company as sgeat for a rcpLcemcal The 1.D. tard itdorttadw may be used for vehialc trgistradon and replacing license pLttt. Y your liability insurwee poln• is not in effect, the ]D. wd is no ]wga valid You are requirr4 to maintain fitunda] rapotuibiliry on your vehicle. It is against Pennsylvania 1aa• ro use the I.D. and hwdulmdy such u using the card as proof of fiaancal raponsibiHry after she insuraaa polin• is terrmnatrd. PLEASE SEE REVERSE SIDE IMPORTANT NOTICE REGARDING YOUR FINANCIAL RESPONSIBILITY IDENTIFICATION CARL. This card nurse be carried for produedw trPw demand. It is suggested that yov catty this card in the insured vehidc. R'ARNING: Any owner or registrant of a motor vehicle who drives or permits a motor vehicle to be driven in this State without the required financial responsibility may have his registration suspended or revoked. NOTE: THIS CARD IS REQUIRED WHEN -- (1) You arc involved in an auto accident; (2) You are convicted of a traffic offense other than a parking offtxlse that requires a court appearance; (3) You are stopped for violating any provision of 75 Pa.C.S. (relating to the Vchic]e:Code) and requested to produce it by a police officer. You >mtst prm•idc a copy od this card m the Dcpartmm[ ad Traaryonadw a$ea yov requut ratwadw of your opaadng pri.•ilcgc and/m regisaadoa pd.•Dege ahirb has been psn3ously suspcadod or revoked. Tnc Old Guard huuranu Compam• is tegtdrrA by Penasyhaaia Lv to seed you as 1D. card. The cud shows that as insunace polity has been issued for the vrhidds) described satisfying the fmaaeal ruponsibility regtdremeats of the ]aa•. H you lose the card, ewua your iastaaau company or agent for a rcplsamcat The l.D. card iaformatiw may be used for vehicle registradw and rcpladng license plats. if your li-bility instaaau polity is not is efreG, the I.D. card is ao lwga valid. 1'ou arc regtdred to maintain finandal responsibility w your vehicle. It is against Pennsylvania laa• to use the ID. card Sauduleady sorb as using the card as proof of fiaaadal responsibility aftc the iasuranu policy is tcr~nau;d. PLEASE SEE REVERSE SIDE =f'-,5°°Ex,6°°' ~ 4„dt-I-ILIHL Ubt U(YLT COMMONWEALTH OF REV -15 0 0 ~ ..., n PENNSYLVANIA ~ ~ "~ EVENUE DEPAR T INHERITANCE TAX RETURN - _ __ FILE NUMBER SO60 DEPT PA 17128-0601 HARRISBURG ~ ~ ~ o>? ~ ~ ~ - - , RESIDENT DECEDENT 0 NTYCDDE YEAR NUMBER DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) :iOCIAL SECURITY NUMBER Z BALDWIN, GARY L. 195 38 8.791 W DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DUPLICATE WITH THE W MARCH 16, 2002 APRIL 27, 1947 REGISTER OF WILLS W (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) :iOCIAL SECURITY NUMBER ~ - - BALDWIN LINDA M. ~ ®1. Original Retum ~ 2. Supplemental Return ~ 3. Remainder Return (date oraeam priorto t2-is-ss) a ~, w a ~ ~ 4. Limited Estate ~ 4a. Future Interest Compromise (date or aeatn after tz-tz-ez) ~ 5. Federal Estate Tax Return Required ~ a m ~ 6. Decedent Died Testate (Attach ~opyotwiq ~ 7. Decedent Maintained a Living Trust (Attacn copy orrn,sc) _ 8. Total Number of Safe Deposit Boxes a a X^ 9. Litigation Proceeds Received ~ 10. SpoUSal POVerty Cfedlt (date of death between 12-31-91 and 1-1-95) 11. Election to tax under Sec. 9113(A) (Attach sch o) w o NAME DAVID W. KNAUER, ESQUIRE COMPLETE MAILING ADDRESS 0 411A EAST MAIN STREET y FIRM NAME pr Applicable) ~ MECHANICSBURG a TELEPHONE NUMBER - ~ - - ~ (717) 795-7790 17055-~: PENNSYLVANIA, 1. Real Estate (Schedule A) (1) NONE OFFICIAL USE ONLY 2. Stocks and Bonds (Schedule B) (2) NONE 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) NONE 4. Mortgagi;s 8 Notes Receivable (Schedule D) (4) NONE 5. Cash, Bank Deposits & Miscellaneous Personal Property (5) 1 7 , 0 0 0 Z (Schedule E) _ 6. Jointly Owned Property (Schedule F) (6) 8 , 2 2 9 (SpOUS2 ) Separate Billing Requested ~ NONE 7. Inter-~vos Transfers & Miscellaneous Non-Probate Property (7) H a Q V w a Z a H a V (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) (g) 7 4 , 3 4 2 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 1 , 61 5 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (81 1 7, 000 (11) 75 , 957 (12) _ n _ (13) NONE (14) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) x .0 _ (15) 16. Amount of Line 14 taxable at lineal rate 1 5 , 0 0 0 x .0 4 55 (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 - 675* 675 Decedent's Complete Address: STREET ADDRESS 12 E. Green Street clTV Mechanicsburg STATE PA zIP 17055 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. InteresUPenalty if applicable D. Interest E. Penalty (1) 675 Total Credits (A + B + C) (2) Total InteresUPenalty (D + E ) 4. If Line 2 is greater than tine 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. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (3) (4) (5) 6 7 5 (5A) (58) 6 7 5 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :.................................................................................... ...... ^ ^x b. retain the right to designate who shall use the property transferred or its income : ...................................... ...... ^ X^ c. retain a reversionary interest; or .................................................................................................................... ...... ^ d. receive the promise for life of either payments, benefits or care? ................................................................ ...... ^ x^ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ........................................................................................................ ...... ^ X^ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ........ ...... ^ X^ 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. 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. SIG ATUR~~ pERSO~V RESP~ SI~`FOR FILING RETURN '~ ~ ~~~~~~ n~~. DATE tD ~ L r ~© 12 E. Green Street, Mechanicsburg, PA 1055 THAN REPRESE DATE !~ -~ Z- ADDRESS 411A E. Main Street, Mechanicsburg, PA 17055 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. * ATTACHMENT TO RECAPITULATION 1. Line 6 Jointly owned property is transferred form Schedule F and is the 50% taxable portion of the Decedent's estate after deducting the 50% non- taxable portion that went to the widow under the intestacy statute. 2. Line 9 Total Deductions reflects the attribution of 50% of the Deductions between the widow and the surviving children; $37,171. 3. Line 16 Amount of Line 14 taxable at the lineal rate reflects the Commonwealth agreement that 80% of the Settlement of the claims against the tortfeasor and the Decedent's Underinsured Motorist provision of his policy as set forth under Schedule E that results in an agreed upon tax of .045 x $15,000 or a tax of $675. rev-,soeex.l,~sn ,• COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER BALDWIN, GARY L. 2002-00408 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1, Personal Effects 2,000 2. I Settlement of Survival and Wrongful Death .Actions 115,000 per attachment. 3. Bank account and timeshare - non-taxable property by entireties by operation of law became spouse's property and therefore is non-taxable. TOTAL (Also enter on line 5, Recapitulation) I $ 1 7 , 0 0 0 (If more space is needed, insert additional sheets of the same size) SCHEDULE E CASH. BANK DEPOSITS AND MISCELLANEOUS PERSONAL PROPERTY' 1. Personal Effects $ 2,000 2. Settlement of Survival Action and Wrongful Death Actions 15,000 per attached. 3. Bank Account and Timeshare valued at $16, 458: Non Taxable because property by entireties with spouse and therefore non-taxable. See, also Schedule F. Total $17,000 ATTACHMENT TO SCHEDULE E The Administratrix and two adult children survived the death of the Decedent. Consequently, his estate was divided in accordance with the intestacy statute; 50% non-taxable to the widow and 50% taxable to the Decedent's children. The Decedent's Survival claim and Wrongful Death claim were settled for $150,000. Based on the intestacy statute the 50% of the total settlement was non-taxable to the widow. The Department of Revenue agreed to an apportionment between the Survival claim and the Wrongful Death claim of 80% for the Wrongful Death claim and 20% for the Survival claim. That letter is attached to this Inheritance Tax Form. Based on the aforesaid agreement, 20% of the $75,000 to be divided between the surviving children is $15,000. The Administratrix received the settlement funds at two different times because they were from two different insurance companies; the tortfeasor's insurance company (Nationwide Insurance Company) and the Decedent's and the Administratrix's insurance company for Underinsured Motorist coverage (Westfield Group formerly Old Guard Mutual Insurance Company). The Administratrix received the $100,000 form Nationwide Insurance Company on July 1, 2002 and from the Westfield Group on August 26, 2002. r` 7/19/2002 David W Knauer, Esquire Knauer & Associates 411A East Main Street Mechanicsburg, Pa 17055 COMMONWEALTH OF PENNSYLVANIA- • • - •• - - - DEPARTMENT OF REVENUE Q~t~~~~~' ~ 3 ~~ BUREAU OF INDIVIDUAL TAXES DEPARTMENT 280601 HARRISBURG, PA 17128-0601 Telephone 717-783-0972 Re: Estate of Gary L Baldwin File Number: 2102-0408 Court Number: Cumberland-Orphans-21-02-0408 2002 Deaz Mr. Knauer: The Department of Revenue has received the Petition for Approval of Settlement Claim to be filed on behalf of the above-referenced Estate in regard to a wrongful death and survival action. It has been forwarded to this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to settle the actions. Pursuant to the Petition, the 54 year old decedent died as a result of a motor vehicle accident. Decedent is survived by the decedent's spouse and two adult children from a prior marriage. Please be advised that, based upon these facts and for inheritance tax purposes only, this Department has no objection to the proposed allocation of the gross proceeds of this action, $ 80,000.00 to the wrongful death claim and $ 20,000.00 to the survival claim Proceeds of a survival action aze an asset included in the decedent's estate and aze subject to the imposition of Pennsylvania inheritance tax. 42 Pa.C.S.A. §8302; 72 P.S. §§9106, 9107. Costs and fees must be deducted in the same percentages as the proceeds are allocated. In re Estate of Merr,nnan, 669 A.2d 1059 (Pa. Cmwlth. 1995). I trust that this letter is a sufficient representation of the Department's position on this matter. As the Department has no objections to the Petition, an attorney from the Department of Revenue will not be attending any hearing regarding it. Please contact me if you or the Court has any questions or requires anything additional from this Bureau. Finally, the approval of this allocation is limited to this estate and does not reflect the position that the D.rart:.^_eat TM.ay *.zke in a*:y ether proposed dis+r'bLtion of proceeds of a ~wrongfial death /survival action. aul Di Inheritance Tax Division Bureau of Individual Taxes cc: Cumberland County Clerk of Orphans Courts RSV-1509 EX ~ (1-97) ' ~ SCHEDULEF COMMONWEALTH OF PENNSYLVANIA JOINTLY•OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER BALDWIN GARY L. 2002-00408 Han 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 12 E. Green Street, Mechanicsburg, PA 17055 RELATIONSHIP TO DECEDENT A. Linda M. Baldwin B. C. .IrnnlTl v-nwNED PROPERTY: Spouse ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY Include name of financial institution and bank account number or similar identifiring number. Attach deed for jointly-held real estate. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. 10/9 Time Share - Orange Lake Resort 13,000 50 6,500 & Country Club 2 A Bank Account 3,458 50 1,729 TOTAL (Also enter on line 6, Recapitulation) I $ 8 ~ 2 2 9 (If more space is needed, insert additional sheets of the same size) SCHEDULE F-CASH. BANK DEPOSITS AND MISCELLANEOUS PERSONAL PROPERTY SETTLEMENT OF SURVIVAL ACTION AND WRONGFUL DEATH ACTIONS' Total Settlement for both Survival Action and Wrongful Death claims: $150,000 Decedent died intestate thereby resulting in a gross division of 50% for wife and 50% divided between two adult children: Linda M. Baldwin (spouse) $75,000 non-taxable Gary L. Baldwin, Jr. (son) $37,500 taxable Sharon Baldwin (daughter) $37,500 taxable Total Settlement $75,000 Per attachment, $75,000 settlement apportioned 80% Wrongful Death claims and 20% Survival Action. Taxable portion of settlement after application of the aforesaid division $15,000 Tax @ .045 for lineal inheritance applicable for decedent's children $675.00 ' The Administratrix received the settlement funds on two occasions: July 1, 2002 $100,000 and August 26, 2002 $50,000. The $100,000 payment was the policy limit from Nationwide Insurance for its insured Matthew Kerman and the $50,000 was the Court approved division of the single limit Underinsured Motorist coverage of the decedent's and the Administratrix's automobile insurance policy limit from the Westfield Group PkV.S11E%•(1.97) • SCHEDULE H COMMQNWEALTHOFPENNSYLVANlA FUNERAL EXPENSES & 1NHERRANCE TAX RETURN ADMINISTRATIVE COST5 RESIDENT DECEDENT ESTATE OF BALDWIN, GARY L. 2002 00408 Debts of decedent must be reported on Schedule 1. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. 2 B. 1 2. 3. 4, 5. s. 7. 8. MYERS FUNERAL HOME, INC. CUMBERLAND VALLEY MEMORIAL GARDEN - GRATZE OPENING - HEAD STONE ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative (s) L N ,j~ M_. ~AI~OWZN_ Social Security Numbers} ! E4N Number of Parsanal Representatives) ~` ~-_ Street Address 12 E. GREEN STREET City MECHANICSBURG State PA Zip 17055 Year(s) Commission Paid: AUomeyFees DAVID W. KNAUER, ESQUIRE Family Exemptan: (lf decedent's address+s not the same as ciaimani's, aHach explanatbn) Claimant N f A Street Adtlress City State Zip „ Relationship of Claimant io Oecedenl Probate Fees CUMBERLAND COUNTY REGISTER OF WILLS INHERITANCE TAX FILING FEE Accountant's Fees NONE TaxRetumPreparersFees INCLUDED IN ATTORNEY FEES ESTATE ADVERTISING - CUMBERLAND CO. LAW 30URNAL THE SENTINEL Contingent Fee against individual whose negligence caused death of decedent and underinsured motorist coverage on own insurance policy 8, 061 850 2,894 7,504 4,815 45 15 75 87.35 50,000 TOTA1. (Also enter on Nne 9, Recapitulation) ~ ~7 4 , 3 4 2 (rt mace spacers needed, insert additional sheets of tite same site) .. ~ ' REV-151E EX+ (193) COMMONWEAUH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE BALDWIN, GARY L. SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES AND LIENS Please Print or FILE NUMBER 2002-00408 (!f more space is needed, insert oddifional sheets of same size.) REV-1513 E%~ (1-971 • '~ . •. SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER BALDWIN, GARY L. 2002-00408 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS (include outright spousal distributions) 1• GARY L. BALDWIN, JR. SON 25 2. SHARON BALDWIN DAUGHTER 25 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE, ON REV 1500 COVER SHEET II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1• LINDA M. BALDWIN (wife) 50~ B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET 13 1 0 0 $ (If more space is needed, insert additionai sheets of the same size) O CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: GARY L. BALDWIN Date of Death: March 16 2002 Will No. 2002-00408 Admin. N To the Register: I certify that notice of beneficial interest required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on May 2, 2002 Name Address Linda M Baldwin Widow & Administratrix -12 E. Green St., Mechanicsburg, PA. Opened Estate 17055 Gary Baldwin Jr Son - 803 Royal Crest Dr. Martinsburg, WV 25401 Sharon Baldwin Daughter - 211 E Washington St., Hagerstown, MD 21740 Notice has now been given to all persons entitled thereto under Rule 5.6 (a) except None Date: October 11, 2002 Sign 7i~ ; W Name: David W. Knauer Address: 411A E. Main Street ., Mechanicsburg, PA 17055 Telephone: (717 795-7790 Capacity.: Personal Representative X Counsel for personal representative @UREAU,.®F INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEwT. 286601 HARRISBURG, PA 17128-6661 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX REY-1547 E% AFP (O1-OS) DATE 02-03-2003 ESTATE OF BALDWIN GARY L DATE OF DEATH 03-16-2002 FILE NUMBER 21 02-0408 ~.: ';_'.' _~ COUNTY CUMBERLAND DAVID W KNAUER ESQ ACN 101 KNAUER & ASSOCS Amount Remitted 411A E MAIN ST MECHANICSBURG PA 1705b'~ 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 BALDWIN GARY L FILE NO. 21 02-0408 ACN 101 DATE 02-03-2003 TAX RETURN WAS: ( ) ACCEPTED AS FILED ( X) CHANGED SEE ATTACHED NOTICE 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 Cl (3) .00 submit the upper portion 4. Mortgages/Notes Receivable [Schedule D) (4) .00 of this fora with your 5. Cash/Bank Deposits/Misc. Personal Property [Schedule E) [5) 2,000.00 tax payment. 6. Jointly Owned Property (Schedule F) (6) .00 7. Transfers [Schedule G) (7) 15,000.00 B. Total Assets (g) 17,000.00 APPROVED DEDUCTIONS AND EXEMPTIONS: 74,342.00 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9) 10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) 1,615.00 11. Total Deductions (ll) 75.957.00 12. Net Value of Tax Return (12) 58,957.00- 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) (13) .00 14. Net Value of Estate Subject to Tax [i4) 58,957.00- NOTE: if an assessment was issued previously, lines 14, 15 andior 16, 17, 18 and 19 will reflect figures that include the total of ALL returns assessed to date. ASSESSMENT OF TAX: 00 00 . 00 15. Amount of Line 14 at Spousal rate (15) • = X 16. Amount of Line 14 taxable at Lineal/Class A rate (16) 15, 000.00 X 045 . 675.00 17. Amount of Line 14 at Sibling rate (17) •00 X 12 .00 18. Amount of Line 14 taxable at Collateral/Class B rate (18) .00 X 15 .00 19. Principal Tax Due (19)= 675.00 TAV f-pCf1TTC. rArncni Rc4.c+r( ~+~~~~^( ~T, AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) INTEREST IS CHARGED THROUGH 02-18-2003 AT THE RATES APPLICABLE AS OUTLINED ON THE REVERSE SIDE OF THIS FORM TOTAL TAX CREDIT .00 BALANCE OF TAX DUE 675.00 INTEREST AND PEN. 6.19 TOTAL DUE 681.19 ^ 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" (CRI, YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) REV-1470 EX (6-88) INHERITANCE TAX EXPLANATION COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE OF CHANGES BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG PA 17128-0601 DECEDENTS NAME FILE NUMBER BALDWIN,GARY L 2102-0408 REVIEWED BY ACN Kathryn Harbilas 101 ITEM SCHEDULE NO, EXPLANATION OF CHANGES Transfer held assets are taxable to the survivors. No deductions can be claimed against joint property as it was not the responsibility of the survivors to pay the debts. Row Page 1 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT KNAUER DAVID W ESQUIRE 411 A EAST MAIN STREET MECHANICSBURG, PA 17055 REV-1162 EX111-96) NO. CD 002144 ACN ASSESSMENT AMOUNT CONTROL NUMBER told ESTATE INFORMATION: ssrv: is5-38-87si FILE NUMBER: 2102-0408 DECEDENT NAME: BALDWIN GARY L DATE OF PAYMENT: 02/10/2003 POSTMARK DATE: 02/08/2003 COUNTY: CUMBERLAND DATE OF DEATH: 03/ 1 6/ 2002 101 ~ $6$1.19 TOTAL AMOUNT PAID: REMARKS: DAVID W KNAUER ESQUIRE SEAL CHECK#1048 INITIALS: AC RECEIVED BY: DONNA M. OTTO 5681.19 DEPUTY REGISTER OF WILLS REGISTER OF WILLS F ;, r I i ~}~~ ~ '^. .~ ~~~~~ y ~ ~ ~;,-~ ~,> r ~,. `° -1 °- ~>>f `~,~ - '''~ - ~~ ~~~_. ~= m ~~ ~~ ~~.~ tr: ;.; t' ~ •.; i'.~ •r•! j p! •r•1 BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280681 HARRISBURG, PA 17128-0601 DAVID W KNAUER ESQ KNAUER & ASSOCS 411A E MAIN ST COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX MECHANICSBURG PA 17055, REV-1547 E% AFP (S1-RS7 DATE 02-03-2003 ESTATE OF BALDWIN. GARY L DATE OF DEATH 03-16-2002 FILE NUMBER 21 02-0408 ,:.QOUNTY CUMBERLAND ACN 101 Amount Remitted MAKE CHECK PAYABLE AND EMIT 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 OEc DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF BALDWIN GARY L FILE N0. 21 02-0408 ACN 101 DATE 02-03-2003 TAX RETURN WAS: [ ) ACCEPTED AS FILED ( X) CHANGED SEE ATTACHED NOTICE RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) Z. Stocks and Bonds (Schedule B) 3. Closely Held Stock/Partnership Interest (Schedule Cl 4. Mortgages/Notes Receivable (Schedule D) 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets APPROVED DEDUCTIONS AND EXEMPTIONS: (1) .00 NOTE: To insure proper (2) .00 credit to your account, (3) .00 submit the upper portion (4) .00 of this fora with your [5)_ 2,000.00 tax payment. (6) .00 (7) 15 ~ 000.00 (g) 17, 000.00 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9) 7 4,3 42.00 10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) 1.615.00 11. Total Deductions (11) 7q .9~7 . 00 12. Net Value of Tax Return (12) 58,957.00- 13. Charitable/Governmental Bequests; Non-elected 9113 Trus ts (Schedule J) [13) .00 14. Net Value of Estate Subject to Tax (14) 58,957.00- NOTE: if an assessment was issued previously, lines 14, 15 andior 16, 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 (151 . 0 0 X 0 0 _ . 0 0 16. Amount of Line 14 taxable at Lineal/Class A rate (16) 15, 000.00 X 045 . 675.00 17. Amount of Line 14 at Sibling rate (17) .00 X 12 - .00 18. Amount of Line 14 taxable at Collateral/Class B rate (18) .00 X 15 - .00 19. Principal Tax Due (lq)= 675.00 TAY f+D e*1T rt+. ------- DATE NUMBER + INTEREST/PEN PAID (-) AMOUNT PAID TWTCDCCT TC ,+uwn.+r~ ---._..__. -.. .,..r,....~., ~~~~wvn vc-io-cuu~ AT THE RATES APPLICABLE AS OUTLINED ON THE REVERSE SIDE OF THIS FORM TOTAL TAX CREDIT .00 BALANCE OF TAX DUE 675.00 INTEREST AND PEN. 6.19 TOTAL DUE 681.19 * IF PAID AFTER DATE INDICATED, SEE REVERSE ( IF TOTAL DUE IS LESS THAN 51, 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 THI5 FORM FOR INSTRUCTIONS.) ~~s~9~ BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX BIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 DAVID W KNAUER ESQ KNAUER & ASSOCS 411A E MAIN ST COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT ~. MECHANICSBURG P'A':17055 REY-1607 EX AFP (O1-OS) DATE 02-24-2003 ESTATE OF BALDWIN GARY L DATE OF DEATH 03-16-2002 FILE NUMBER 21 02-0408 COUNTY CUMBERLAND ACN 101 Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment. CUT ALONG THIS LINE - RETAIN LOWER PORTION FOR YOUR RECORDS ~ ---------------------------------------------------------------------------------------------------------------- REV-1607 EX AFP (01-03) ~*~ INHERITANCE TAX STATEMENT OF ACCOUNT x*~ ESTATE OF BALDWIN GARY L FILE N0. 21 02-0408 ACN 101 DATE 02-24-2003 THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUE, APPLICATION OF ALL PAYMENTS, THE CURRENT BALANCE, AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 02-03-2003 PRINCIPAL TAX DUE: PAYMENTS (TAX CREDITS): 675.00 PAYMENT DATE RECEIPT NUMBER DISCOUNT (+) INTEREST/PEN PAID (-) AMOUNT PAID 02-08-2003 CD002144 5.27- 681.19 TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. * IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN S1, 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. ) 675.92 .92CR .00 .92CR Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17013 Phone: (717) 240-6345 Date: 2/02/2005 KNAUER DAVID W 411A E MAIN ST MECHANICSBURG, PA 17055 RE: Estate of BALDWIN GARY L File Number: 2002-00408 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, N0. 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: 3/16/2005 Your prompt attention to this matter will be appreciated. Thank You. Sincerely, GLENDA FARNER STRASBAUGH REGISTER OF WILLS cc: File Personal Representative(s) Judge STATUS REPORT UNDER RULE 6.12 Name of Decedent: Gary L. Baldwin Date of Death: 3/16/02 Will No. 2002-00408 Admin. No. 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 administration of the estate is complete: Yes X No _ 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: JLitigation Only, No. Assets 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 No X b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes X No d. Copies of receipts, releases, joinders and approvals of formal or informal accounts maybe filed with the Clerk of the Orphans' Court and maybe attached to this report. /~ r ' i. Date: 2/08/05 gna e David W. Knauer, EscLuire ~~~ Name (Please type or print) .:. _ ~._- 411A E. Main St., Mechanicsburg, PA17055 ~, ' ~ Address (717) 795-7790 ~ Tel. No. Capacity: Personal Representative X Counse for Personal Rep.