HomeMy WebLinkAbout06-27-14 (2) s ,
� 1505610105
REV-1500�`�02_11,��,��
PA Department of Revenue pennsylvania OFFICIAL USE ONLY
Bureau of Individual Taxes °`•""'"`"`°`"`�`"°` Couniy Code Year File Number_ _
INHERITANCE TAX RETURN ;— -- ^- - —
PO BOX 28o6oi ' /� �
Harrisburg,PA i�1z8-o6oi RESIDENT DECEDENT ' Z� � 3 ' � �d �
_ _ _ ---
ENTER DECEDENT INFORMATION BELOW
10/05/2013 05/19/1934
=----�----.._._.._..__....---------------�
-----...__._...--------._.................._...: .-----._._.....__._...---------..._.__..._.._..._....._...:
DecedenYs Last Name Su�x DecedenYs First Name MI
Bolze ; Kenneth ;W ;
_ ..._.. ..__.___._...._..__....----._...__...._._......---___..._.___.._...._..._..._.__..._. _.._.,.�
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
n/a
--------....----..__...------------------......_........_...._._....__.................._......._.._......_...._....---------..__.._....: �___..---....---..__...._......_: :,......__.........._.._......----�-------.._..---------......_...._....__.......---------...._....__......__........_... ............__.,
Spouse's Social Security Number
���-���'� �����������- THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� 1.Original Retum O 2.Supplemental Return p 3. Remainder Retum(Date of Death
Priorto 12-13-82)
O 4.Limited Estate p 4a.Future Interest Compromise(date of O 5. Federal Estate Tax Return Required
death after12-12-82)
� 6.Decedent Died Testate O 7.Decedent Maintained a Living Trust 1 8. Totai Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust.)
O 9.Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 11. Election to Tax under Sec.9113(A)
Between 12-31-91 and 1-1-95) (Attach Schedule O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
___________m__._.._..__._..�_____ ___._..______-_-_-___._._.___..___.___..--.�___�___.____._.,
Ronald E. Johnons, Esq � ;(717)243-0123���^ � ?
�---------.._..----......._.._._....._..___..._.._..----.._._.._..._...._...----------.._........_._..---- —---------- ;
------._......_. : _....._..._..—..._...----.._......_.__._.—._.�
_. ----._....----...
REGIST�!OF WILLS US6ZINLY•''- �
—�. c� �'°� �""�
(,J � G ..;1 C3
First Line ofAddress �'� - 'G �-'� "�
. :.,
----------------._..__....—.. _. __....--------------
_. -- --...._.. _.__._._ __ 7 - . .. t-:,'r
'.78 West Pomfret Street :. ° • " N °' ��`"
..,._ .� :_.
;..------------....__.._..__.._....__...---....-----------___............._....__.........._.._..__------...._......---..__......--------.._...-----------....----._..__......---..__.._......-------..; ° �::� : .
Second Line of Address { � �� '' ' �'
-------------......__..__.._.......---... _............._......--------------
---------...----._...-------.._.__..__..._...._
1
�,� �,.� � ..,.r L�
C-,,. <.'s -y 7 �
<� C W: �r
��._____._.��_�._._._��____._.._..____. ____ _�___�.��____.._._.__.. ' �7E FILED �"`�
City or Post Office State ZIP Code '
_.____�..__,____.�_.__.�_..�__.._____.___._---_ _._---...........-----..._..-- --.._.
__.__ __..._�, ,_______,., --__.._.._.---.-------...
Carlisle ; PA �17013 y" � U' -°,�
0
CorrespondenYs e-maii address:rejohnson@pa.net
Under penaities of perjury,I declare that I have examined this retum,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is Vue,conect and complete.Declaration of preparer other than the personal representative is based on ail information of which preparer has any knowledge.
S GN F PERSON RE ONSIBL R FI ING RE RN D E � /
ADDR SS
c/o 78 t Pomfret Str t, lisle, PA 17013
SI R OT ESENTATIVE DATE
C
R S
G 78 West Pomfr Street, Carlisle, PA 17013
PLEASE USE ORIGINAL FORM ONLY
Side 1
� 15056101�5 1505610105 �
��
1 �
� 1505610205
REV-1500 EX(FI)
RECAPITULATION
1. Real Estate(Schedule A). ............................................ 1. ; 170,000.00
2. Stocks and Bonds(Schedule B) ....................................... 2. ; 0.00
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) ..... 3. : 0.00 :
4. Mortgages and Notes Receivable(Schedule D)........................... 4. ; 0.00 :
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)....... 5. 58,437.32
6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. i 0.00
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property °-'°°"""'�"'�"'"mm�'-""""""'.`_�___w.,..��__._�;
(Schedule G) O Separate Billing Requested........ 7.; 174,084.90 ;
8. Total Gross Assets total Lines 1 throu h 7 8, s 402,522.22 ;
� 9 ).............................
9. Funeral Expenses and Administrative Costs(Schedule H)................... 9. ; 28,977.65 ;
10. Debts of Decedent,Mortgage Liabilities and liens(Schedule I)............... 10. ; 96,573.96
11. Total Deductions(total Lines 9 and 10)................................. 11. ; 125,551.61 ;
12. Net Value of Estate(Line 8 minus Line 11) 12. 276,970.61
..............................
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which '""�'�'�'"��
an election to tax has not been made(Schedule J) ........................ 13. 0.00
14. Net Value Subject to Tax(Line 12 minus Line 13) ........................ 14. ; 0.00
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfersunder Sec.9116 ---------._....._...__.............._....---..___....-----.._.._...._..........---_____.._... _..__.._..----......_.._.._......_........-------�-----............----------------...._..__...._.._:
(a)(1.2)X.0_ 15.'
16. Amount of Line 14 taxable �� ��
at Iineal rate X.0 45 241,122.52 �6,; 10,850.51
17. Amount of Line 14 taxable ���' ����� �� �����
at sibling rate X.12 17•,
18. Amount of Line 14 taxable
at collateral rate X.15 35,848.09 ; �g.; 5,377.21
19. Tax DUE......................................................... 19.' 16,227J2 ;
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Side 2
� 1505610205 150561�205 �
,
REV-1500 EX(FI) Page 3 File Number
Decedent's Complete Address:
DECEDENTS NAME
Kenneth W. Boize
STREETADDRESS
4 White Oak Drive
CITY STATE ZIP
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 16,227.72
2. CreditslPayments
A.Prior Payments 0.00
B.Discount 0.00
Total Credits(A+B) (2) 0.00
3. Interest
(3) 0.00
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2,Line 20 to request a refund. (4) 0.00
5. If Line 1+Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 16,227.72
Make check payable to: REGISTER OF WILLS,AGENT.
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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 inwme of the property transferred.......................................................................................... ❑ �
b. retain the right to designate who shall use the property transferred or its income............................................ ❑ �
c. retain a reversionary interest.............................................................................................................................. ❑ �
d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ �
2. If death occurred after Dec.12,1982,did decedent transfer property within one year of death
without receiving adequate consideration?.............................................................................................................. ❑ �
3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?.............. ❑ �
4. Did decedent own an individual retirement account,annuity or other non-probate property,which
contains a beneficiary designation? ........................................................................................................................ � ❑
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
1' .P'7°� ,,� ..�� '� �"' ...y��°"-X�,���r.w��,�rnh'�+rv' s � fl+r -arr ,a�-.r � -s . v' ,m�' nr�; rn�.���.�<'r'w"'� u ,� - z . w�° ,z�,.!�
�����a:.�i'��.�wM:��;�.""'�..,.�'�e,�w':.�-X;°'r.af'�'�f�'�✓"aa..�e.x55...r.:s�,,saats.��„�,:v�...a.tw.,..,t?'_sa Y ° �wr � ..�� �i � �s
- _ .�..�,K,.,.._..,..�.w...,..�.:..�.c,.�.wr�'�'�siusr.,aw,a�'�w�.a��,.,..r..< - uu,Ma....�..�.��:a.;a,s:.0 Ycas�s"aa':.'«.��
For dates of death on or after July 1,1994,and before Jan.1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is 3 percent[72 P.S.§9116(a)(1.1)(i)].
For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the suroiving spouse is 0 percent
[72 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and
filing a tax retum are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1,2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an
adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)].
. The tax rate imposed on the net value of transfers to or for the use of the decedenYs lineal beneficiaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)].
. The tax rate imposed on the net value of transfers to or for the use of the decedenYs siblings is 12 percent[72 P.S.§9116(a)(1.3)].A sibling is defined,
under Section 9102,as an individual who has at least one parent in common with the decedent,whether by biood or adoption.
, ,
LAST WILL AND TESTAMENT
OF
KENNETH W. BOLZE
I, KENNETH W. BOLZE, of Dickinson Township, Cumberland County, Pennsylvania,
being of sound and disposing mind,memory and understanding,do hereby make,publish and declare
this as and for my Last Will and Testament,hereby revoking all other wills and codicils heretofore
made by me.
FIRST: I direct that all my just debts and funeral expenses,including my grave
mazker, shall be paid from the assets of my estate as soon as practicable after my decease.
SECOND: I give and bequeath the following properry together with any insurance
thereon as follows:
A. To my son, THOMAS A. BOLZE, I give and bequeath his mother's piano,
my roll top desk,two small end tables made by his great-grandfather,the red and
gray afghan made by his great-grandmother, his mother's wedding and
engagement ring and my wedding bands.
B. To my son,MARK A.BOLZE,I give and bequeath any vehicle together with
° any insurance thereon owned by me at the time of my death, all of my guns and
hunting equipment(to share as Mark shall deternline in his sole discretion with
his brother, Victor), and the gun cabinet made by his great-grandfather. ;
C. To my son,VICTOR M. BOLZE,I give and bequeath the long narrow table '
that was his mother's, my dresser (which had been his), the desk made by his �
grandfather, and any and all camping equipment owned solely by me. 4
i
�
THIRD: I give, devise and bequeath the residue of my estate, of every nature �
and wherever situate,to my three sons,namely, THOMAS A. BOLZE, MARK A. BOLZE and �
VICTOR M.BOLZE,provided that the shaze of any of my sons who may predecease me shall be
distributed to issue per stirpes living at the time of my death and in default of such then living issue,
such share shall be added to the shaze or shares for my other children.
i
FOURTH: I direct that a11 taxes that may be assessed in consequence of my death,
of whatever nature and by whatever jurisdiction imposed,shall be paid from my residuary estate as a ;
part of the expense of the administration of my estate. �
�
�
�
FIFTH: I nominate, constitute and appoint my son, THOMAS A. BOLZE,
Executor of this my Last Will and Testament. Should my son,THOMAS A.BOLZE,fail to qualify
or cease to act as Executor,I appoint my son,MARK A.BOLZE,Executor ofthis my Last Will and
Testament. Should both my sons,THOMAS A.BOLZE and MARK A.BOLZE,fail to qualify or
cease to act as Executors,then and in that event,I appoint my son,VICTOR M.BOLZE,Executor
of this my Last Will and Testament.
SIXTH: I direct my Executor and his successors shall not be required to give
bond for the faithful performance of their duties in this or any other jurisdiction.
IN WITNESS WI�REOF,I have hereunto set my hand and seal to this,my Last Will�nd
Testament,consisting of two(2)typewritten pages,each identified by my signature,this f3 f�C
day of May 2009.
(SEAL)
enne W. Bolze
Signed,sealed,published and declared by the above-named Testator,Kenneth W.Bolze,as
and for his Last Will and Testament, in the presence of us, who, at his request, in his sight and
presence, and in the sight and presence of each other, have hereunto subscribedf6'ur names as
witnesses.
/
r
�
, ,
COMMONWEALTH OF PENNSYLVANIA )
. SS.
COUNTY OF CUMBERLAND )
I, KENNETH W. BOLZE, Testator, whose name is signed to the attached or foregoing
instrument,having been duly qualified according to law, do hereby acknowledge that I signed and
executed the instrument as my Last Will and Testament;that I signed it willingly;and that I signed it �
as my free and voluntary act for the purposes therein expressed.
Sworn or affirmed to and acknowledged before me by Kenneth W.Bolze,the Testator,this
%.S day of May 2009.
i
SEAL)
COMMONINEP►�rtH OF PENNSYl.VANIA Ken e W. Bolze, Testator
NOTARIAL SEAL � ;
l �
SHELLY SEXTON, Notary Public v�,,� 4' /r ,�.- �,
! f.
Carlisle Boro, Cumbe�land County
My Commission Expires April 26, 2011 No�tary Public
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA )
. SS.
COUNTY OF CUMBERLAND )
r----� �
We, RONALD E. JOHNSON and /����,���,- . ��ir��r��:i�?� , the witnesses
whose names are signed to the attached or foregoing instrument, being duly qualified according to '
law,do depose and say that we were present and saw Testator sign and execute the instrument as his
Last Will and Testament;that Kenneth W.Bolze,signed willingly and that he executed it as his free i
and voluntary act for the purpose therein expressed; that each of us in the hearing and sight of the �
Testator signed the Will as witnesses; and that to the best of our laiowledge the Testator was at that '
time 18 or more years of age, of sound mi.nd and under no constraint or undue influence. '
wo or a ''ed to and subscribed to before me by RONALD E. JOHNSON �
and ��.;�cr ��ii--�/��°.s , witnesses,this � !
� day of May 2009. ;
/ �
(SEAL)
nald E. Jo '#� '
�
COMMONWEALI`H OF RENNSYLVANIA ;
NOTARIAL SEAL � , , (SEAL) �
SHELLY SEXTON, Notary Public � ; , �V'tness !
Carlisie Boro, Cumberland County �► �
Commission Ex ires April 26, 2011 � .1J j�r.�/� �1f f� ,,
MY p _ �,
_ - 5�`� �
Notary Pukilic f '.
_,f ! i
i
� REV-150�EX+ (12-12)
�ii�� nt'ennsYlvania SCHEDULE A
�` DEPARTMENT OF REVENUE
INHERITANCE TAX RERIRN REAL ESTATE
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Kenneth W. Bolz 21-13-1085
All real property owned solely or as a tenant in common must be reported at fair market value.Fair market value is defined as the price at which property
would be exchanged between a willing buyer and a willing seller,neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts.
Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F.
Attach a copy of the settlement sheet iF the property has been sold.
ITEM Include a copy of the deed showing decedenYs interest if owned as tenant in common, VALUE AT DATE
NUMBER OF DEATH
DESCRIPTION
1• ALL THAT CERTAIN tract of land situate in Dickinson Township, Cumberland County,
Pennsylvania situate on White Oak Drive known and riumbered as 4 White Oak Drive,
Carlisle,PA 17015
See Deed Book 280 Page 716
Contract sales price 170,000.00
(see settlement statement HUD-1 attached)
TOTAL (Also enter on Line 1, Recapitulation.) $ 170,000.00
If more space is needed,use additional sheets of paper of the same size.
,-Illtlll* OMB Approval No.2502-0265
-;ululu�, � A. Settlement Statement {HUD-1) FINAL
.- . ..
1,Q FHA 2.Q RHS 3.Q Conv.Unins. 6.File Number: 7.Loan Number. 8.Mortgage Insurance Case Number:
2014-040 000008833
4.❑VA 5.Q Conv.Ins.
C.Note:This fortn fs fumished to give you a statement of actual settlement costs.Amounts paid to and by the settlement agents are shown Items marked
"(p.o.c)"were paid outside the closing;they are shown here for infortnational purposes and are not included in the totals
D.Name&Address of Borrower. E.Name 8 Address of Seller: F.Name 8 Address of Lender.
Drew W.Nickel,Jaclyn S.Clifford The Estate of Kenneth W.Boize Orrstown Bank
44 West I Street,Cadisle,PA 17013 4 White Oak Drive,Cariisle,PA 17015 2695 Philadelphia Avenue,Chambersburg,PA
17201
G.Property Location H.Settlement Agent: I.Settlement Date:03/20/2014
4 White Oak Drive PA Real Estate Settlement Services,LLC Disbursement Date:03/20/2014
Carlisle,PA 17015 354 Alexander Spring Road,Cariisle,PA 17015
Dickinson Township
Telephone:717-249-6333 Fax:717-249-7334
Place of Settlement TitleExpress
354 Alexander Spring Road,Carlisle,PA 17015 Printed 03I20/2014 at 9:20 am
by KSC
_
'100: :Gross Amount Due from:Borrower A00:":Gross Amoun[Due:to Seller.
101. Contractsales price 170,000.00 401. ConVactsales price 170,000.00
102. Personal ro e 402. Personal ro e
103. -Serilement charges to borrower(line 1400) 9,131.30 403.
104. 404.
105. 405.
Ad ustments for items aid b seller in advance Ad'ustments for items aid b seller in advance
106. Cityltown taxes to 406. Cityltown taxes to
107. Countytaxes 03/2012014to 12131I2014 323.05 407. Countylaxes 03l2012014to 12/31/2014 323.05
108. Assessments 03/2012014to 06130I2014 567.33 408. Assessments 03f2012014to O6I30/2014 567.33
109. 409.
110. 410.
111. 411.
112. 412.
120. Gross Amount Due from Bonower 780,021.68 420. Gross Amount Due to Seller 170,890.38
200. Amounts.Paid b :or in:Behalf of'Borrower :;? '::: 500,'::ReducEons In:Amo6nf'Due;to Seller. : . >' "' ''
201. Deposit or eamest money 1,000.00 501. Excess deposit(see instrucGons)
202. Principal amount of new loan(s) 153,000.00 502. Settlement charges to seller(line 1400) 13,472.85
203. Existin loa s taken sub'ect to 503. Existin loan s taken sub'ect to
204. 504. Payoff of first mortgage loan to Ortstown Bank 94,407.88
205. 505. Pa off of second mort a e loan
206. 506.
207. - 507. Inheritance Tax Return Escrow 11,475.00
208. 508.
2D9. 509.
Ad'ustments for items un aid b seller Ad'ustments for items un aid b seller
210. Ciry/town taxes to 510. City/town taxes to
211. County taxes to 511. Countytaxes to
212 Assessments to 512. Assessments lo
213. 513.
214. 514.
215. 515.
216. 516.
217. 517.
21 B. 518.
219. 519.
�0• Total Paid b Ifor Borrower 154,000.00 520. Total Reduction Amount Due Seller 719,355.73
300: CashafSettlement fromfto BoROwer <°< `(`. ' '600..-.Cash at Settlement tolfrom Seller. '':. . ` °-
301. Gross amount due from borrower(line 120) 180,021.68 gp�, Gross amount due to seller(line 420) 170,890.38
3D2. Less amounts paid by/for borrower(line 220) 154,000.00 602 �ss reductions in amount due seller(line 520) 119,355.73
303. Cash XQ From ❑ To Bortower 26,021.68 603. Cash X❑ To ❑ From Seller 51,534.65
Nk foml,unlm II O�ISpltq��artanlly WW OMB�mnVOl numEel.ND confbmll�llty 4 a wrtd;�llib ElstlWUn k m�Mal�7NS b 4asynM la povl7a Ne putlas lo i RESPA mvera0lranS�tlion wIN Inlortn�lbn pyN�p�mp e a
•aWemanl pouA
Previous editions are obsolete Page 1 of 4 HUD-1
�.., � � �� . ��� ��. .� .p��,�._
7DOr' Total:Real Es4ate`BrokerFees,::'. ,.. .;' >$'10;495.00 : : ;:` _°' ';;:: Paid From ; Paid From;;
Divi§ionofcommission line700 asfoliowsi >r , `°'
: Bo��ower s' Selle�'s ,
701. $10,495.00 to PrudentialHomesaieServicesGroup FundS at';`` FUnds at"'
702. g0.o0 to 'Setfiement` ::Settlement<:
703. Commission paid at settlement 10,495.00
704. Broker Fee to PNdential Homesale Services Group 300.00
:
800:: `Items:P.a atile in ConnecGon with:Loan :' ` " ' ` ;' '
,;
_
801. Our origination charge (Includes Origina6on Point 0.000%or$0.00) $775.00 (from GFE#t)
802. Your credit or charge(points)for the specific interest rate chosen $ (from GFE#2)
803. Your adjusted origination charges (from GFE A) 775.00
804. Appraisal fee to Central Penn A raisals $400.D0 P.O.C.B'(from GFE#3)
805. Credit report to CBC Innovis,Inc. (from GFE#3) 66.35
806. Tax service to from GFE#3
807. Flood certification to CBC innovis (from GFE#3) 10.00
808. to
900i: Iteme:Re uGed b Cenderto be Peid iri Advance:.':>> '
,.;. , . ,...
901, Daily interest charges from from 0312012014 to 0410112014 @$18.86001day (from GFE#10) 226.32
902. Mortgage insurance premium fw months to Genworth Fnancial (from GFE#3) 2,096.10
903. Homeowners insurance for 1 ears to State Farm (from GFE#11) 581.00
gp4, months to from GFE#11
, _ ..
1000.'Reserves De osited with Lender °
)
1001. Initial deposit for your escrow account (from GFE#9 1,510.03
1002.Homeowners insurance 3 months $ 48.421month $145.26
1003.Mortgage insurance months $ O.00lmonth $
1004. Pro e taxes months $ Imonth
1005.Countytaxes 3 months $ 34.241month $��2J2
1006.Assessments 10 months $ 167.541month $1,675.40
1007.Aggregate Adjustment $-413.35
_: , ... „
190D:=Titie Char es ,::r ;: ;., ,. ;., ,
, _ ,..
1101.Title services and lenders tiGe insurance from GFE#4 1,494.50
1102. Settlement or closing fee Io $
1103.Owners tiUe insurance from GFE#5 210.00
1104. Lenders title insurance $1,390.00
1105. Lender's Utle policy limit$153,000.00 Lenders Poiicy
1106.Owners tiUe policy limit$170,000.00 Owners Policy
1107.AgenYs portion of the total title insurance premium $1,318.75
1108. Underwriters portion of the total title insurance premium $281.25
1109.Attomey Fees to Ronald Johnson,Es uire 250.00
1200:Govemment Reeordin and Transfer Char es
1201. Govemment recording charges $ (from GFE#7) 162.00
12�2• Deed$67.00 Mort a e$95.00 Release$
1203.Transfer taxes $ (from GFE#8) 1,700.00
1204. CitylCounty ta�stamps Deed$1,700.00 Mort a e$
1205. State Taxlstamps Deed$1,700.00 Mort a e$ 1,700.00
1206. Deed$ Mort a e$
'f300:AdditionafSettlementChar es:::
„ ,..: ,. , ,
1301.Required services lhat you can shop for (from GFE#6)
1302.2014 County Taxes to Carol n McQuillen,Tax Collector 410.85
1303. Home Warranty to AHS 600.00
1304. Final Water Bill to Borou h of Mt.Holl S rin s 17.00
1305. to
•�� � � i 9,131.3D 13,472.85
'Paid outside of ciosing by(B)orrower,(S)eller,(L)ender,(I)nvestor,Bro(I�er.°Credit by tender shown on page 1."'Credit by seller shown on page 1.
Previous editions are obsolete Page 2 of 4 HUD-1
� .
Com arison of Good Faith Estimate'GF and HUD.1:Char es '-::: ' '<. ' " ' Good.Faitti Esfimate" ,:. -:`''' HUD=1 "`
'�ha es7ha'Cannofincrease : :HUD-9 Line Number �.
Our origina6on charge.� .'.-= i`#: 801�.- •` 775.00 775.00.
Your credit or.:charge(points)for the.spec�c interest rate cfiosen #.602 0.00 0.00
Your adjuste.d originaUon charges ` .•#. 803-. .;.- 775.00 775.00
Transfertaxes.'- #: 1203 - 1,700.00 1,700.00
Chai esThat in TotaPCannoflncrease More Than 10%'.'. :' " 600d Faith Estimate=. - .HUD�1 :'' -
Govemment recording charges� - # 1201 .. 150.00 162.00
;Appraisalfee '? - `;.#804 400.00 400.00
;C�editrepoR.'::� - •.#.805 62.70 66.35
Flood certificafion # 807 10.00 10.00
Mortgageinsurance p�emium ,`#;902 , 2,096.10 2,096.10
Title services,and lentler's;title insurance .. - ;'.:�:'�, #,:1101 ';ti�. .. - . 1,615.00 1,494.50
'Owners title insurance .� •• #_:1103..- •- 170.00 210.00
'4:i: ��#;;
4,503.80 4,438.95
� $ -64.85 or -1.4399%
Char es That Can Chan e'
` "" Good Fa'rth Estimater:` `. HU0.1°
ilnitiaideposifforyour..escrowaccount.`.; . . ,#;90D1. ..:�, - 1,919.82 1,510.03
�Daity.interestchargesfrom:,: -. #901 �:.;$18.86001da 282.90 226.32
[:Homeowner'sansurance ,°.; , :.i. #'903 . 581.00 581.00
_ :#,'
� #;'.
- =#
Loan Terms
Yourinitialfoan:amountis `` ; $153,0OO.OD
Yourioan term is: ' 30.years
Your:inidal interest rate is �i �� r ' 4.500D%
Your imUal monthly amount owed for principal'interest and any morlgage $775.23 indudes
irisurance is XQ Principai
, � ❑X Interest
❑Mortgage Insurance
Can your mferest rate nse? `.'; ❑X No. ❑Yes,it can rise to a maximum of %. The first change •
will be on / ! and can change again every years after I I . Every
� change date,your interest rate can increase or decrease by %. Over the life of
�.; �`. the loan,your interest rate is guaranteed to never be lower than %or higher
_ than %.
Even;ff you make.payments on Lme can;your loan balance nse1�' ;: ❑X No. ❑Yes,it can rise to a maximum of$ .
Even;'rf you�make'payments on Ume ran your mon{hlyamountowed for> QX No. ❑Yes,the first increase can be on I I and the monthly
principal mterest;and mortgage insuraqce nse7 ' amount owed can rise to$ .
� .; : a �; The maximum it can ever rise to is$ .
Does your loan hiave a prepayment penaltyl ; QX No. ❑Yes,your mauimum prepayment penalty is$ .
Does,your loan tiave a balloon payment?:; x . 4 QX No. ❑Yes,you have a balloon payment of$ due in
years on / / .
TotaCmonthly amountowed includmg esc�ow accoun4 payments ; ❑You do not have a monthly escrow payment for items,such as property taxes
`'- ' and homeowners insurance. You must pay these items directly yourself.
r ;: QX You have an additional monihly escrow payment of$250.20
. � :,
.
that results in a totai initial monthly amount owed of$1,025.43. This includes principal,interest,ai
` - mortgage insurance and any items checked below:
� ,
-_ _ ; Q Property taxes QX Homeowners insurance
` ;' �Flood insurance ❑
_ ❑ ❑
Note: If you have any questions about the Settlement Charges and Loan Terms listed on this form,please contact your lender.
Previous editions are obsolete Page 3 of 4 HUD-1
HUD CERTIFICATION OF BUYER AND SELLER
I have carefully reviewed the HUa1 Settlement Statement and to the best of my knowledge and belief,it is a true and accurate statement of all receipts and
disbursements made on my account or by me in this trensaction I further certify that I have received a copy of the HUD-1 Settlement Statement
/l� ��� �.�
Drew W.Nickel Jaclyn Clifford
`/��'//L�/ ��i�`�/VL—
THE ESTA E OF KEN ETH W.BOLZE �x
The HUD-t Settlement Statement which I have prepared is a true and accurate account of this transaction I have caused or will cause the funds to be
disbursed in accordance with this statement
�� �� � j� ���
SETTCEMENTAGENT DATE
WARNING:IT IS A CRIME TO KNOWINGLY MAKE FALSE STATEMENTS TO THE UNITED STATES ON THIS OR ANY SIMILAR FORM.PENALTIES UPON
CONVICTION CAN INCLUDE A FINE AND IMPRISONMENT.FOR DETAILS SEE TITLE 18:U.S.CODE SECTION 1001 AND SECTION 1010.
Previous editions are obsolete Page 4 of 4 HUD-1
1 1 1.
Name of Borrower. Name of Seiler. File Number
Drew W.Nickel The Estate of Kenneth W.Bolze 2014040
Jaclyn S.Clifford
TitleExpress
Prepared 03/20I2014 at 921 am
h
Nac�: This page is furnished to give you an itemization of the amounts shown on Lines 1101, 1103 and Paid From ' , Paid�rom '�
tl0¢ of the Settlement Statement (HUD-1�. This page aecompanies but is not a part of the Bor�ower's" ; � Seller's _
settlemmt statement 1F a discrepancy exists,the information shown on the Settlemen[Statement Funds at " �unds at� i�
(HUD-I)applies. Se1tIB1T)8flt = 'Settlement :
,�-, + �� ��+� � , « „ �; � r;� � Amounts Included #5�° F �K � , � --
w.
1700 TitleCharges� � 5 K � � �
_�'r s. • ,^:. .,t +�.,'..r .��� a ._:;?�x r+.� . � -x a;� . ?,t-o III.LIf1E?17D7. !" ' r �"` -
_ ,. , . . . �. , , :.-� ._ ,: F ....
1101. TIUe services and lenders litle insurance 1,494.50
a.Ovemight Mail $ 20.50 �
b.Processing Fee 49.00
c. Notary Fee 35.00
$ 1D4.50
1102. Settlement or closing fee
1103. Owners title insurance (polic) $ 210.00 210.00
1104. Lender's tiGe insurance (policy) 1,165.00 $ 1,390.00
a.Endorsement 900 EPL-Residential 50.00
b.Endorsement 100 No Violation 50.00
c. Endorsement 300 Survey 50.00
d.Closin Service Letter 75.00
(Total 1103+1104)
�10,Sr.Lende['siUllepolicyJimit5153;000,00 ,.��` j .::�: , +;�_�
1106..Owqeds;Utle,polic`rlimd,S170;00000,M t��:' a ` _`< ,` ' . ;:�:{
1•107..,A enYs:'ort�on ofthe total trtle:iri'surance'p�emmm��y ";�$ 1,318.75'�I:�
_ :. ,; ,..,. -.
1:1D8 Uriderwritersporlion-ofthetotal�tiUeinsuranceprem � �. .28125.�i�
� � a ':{ ��a�± w; ,� ',�.(Total 1107�1108) �,.;; ;'i
1109.
1110.
1111.
1112.
�
����?.��.��, r��l�,��i�t,� ._.���yt,�rr�[ { ky'�'4sy t�iy F i ��:�uF Y � i,��t� TO���� -�'. a �'$OffOWCf�;��- y� BOffONRf � ';i $e��Cf Y
�,..�., .:::�., _ fr r� . .Char`e�.. �� POC or Credit ._t;L'irie 1101.., � Paid ._.'
190U:'�7itle'Cha eswitli�Pa ee"�"_�:�;�.,��,.._�� i �'.=
1101. Title services and lenders title insurance $
a.Ovemight Mail to Salzmann Hughes,P.C. 20.50 20.50
b. Processing Fee to Salunann Hughes,P.C. 49.00 49.00
c. Notary Fee to Kamela Comman 35.00 35.00
11D4. Lender's title insurance to Slewart Title GuarantylPA RE SS 1,390.OD 1,390.00
7�.: r ��.:• x,f . _ -�-. Q�" � /�
� v: 4 ..:::� 1 ��:�'� L��. h k 1 �7:� n�- 4hz:�� V 3 1:'� . . 4:W.:.�. ��494:50.. � .�',:: '4 �.', , :-1�QJ45�.n::�'�,.. .� � f `�,•,
,1lN��r.f
THE ESTATE OF KENNETH W.BOLZE
/,/ f/'/
By v` Date 3/20M4 �— 4Y �� Date 3/20/14
Drew W.Nickel
Date 3/20/14 �
Jaclyn S Cli
� ,
REV-iso8 EX+(08-1�)
� pennsylvania SCHEDULE E
DEPARTMENTOFREVENUE CASH� BANK DEPOSITS & MISC.
INHERITANCETAXRENRN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Kenneth W. Bolze 21-13-1085
Include the proceeds of litigation and the date the proceeds were received by the estate.
All properry jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION Of DEATH
�,' ,Checking account no:9843932253-M&T Bank(see letter attached) 19,609.52 '
.. _..
; 2.' 'Savings account no:15004216657899-M&T Bank(see letter attached) 1,380.30 !::
, .�
' 3, Savings account no:185312-00-Members 1st FCU(see letter attached) 25,508.68 '
', 4,'; `Personal property-see appraisal attached 4,765.00 ':
5,' ;2002 Toyota Highlander automobile-good condition;130,000 miles-proceeds from sale 4,000.00 !'.
g.' US Treasury-2013 income tax refund 1,036.00
, 7., Shipley Oil-refund 929.57 "
g.; Canoe-age unknown 200.00 :
g.' Drew W.Nickel&Jaclyon S.Clifford-reimbursement for real estate taxes paid in advance
' {see HUD-1 attached to Schedule A) 890.38 ';
10. '$75 US Saving Bond-cashed 117.87 ';i
, ., ,_,; ,. , , , , ,..
: _
�
TOTAL(Also enter on Line 5, Recapitulation) $ 58,437.32 ?,
If more space is needed,use additional sheets of paper of the same size.
o M�B�
499 Mitchell Road,Millsboro,DE 19966 Adjustment Services
Phone 888-502-4349
F ax (302)934-2955
October 23,2013
Andrews & Johnson
Attorney at Law
78 West Pomfret Street
CarGsle,PA 17013
Re: Estate of Kenneth W. Bolze
Social Securitv: 164-28-2489
Date of Death: October 5.2013
Dear Sir or Madam:
Per your inquiry on October 16, 2013, please be advised that at the time of death, the above-named decedent
had on deposit with this bank the following:
1. Type ofAccount CheckingAccount
AccountNumber 9843932253
Ownership(Names o,fl Kenneth W.Bolze
Mcv�kBolze(POA)
Opening Date 07/27/2007
Balance on Date of Death $ 19,609.46
Accrued Interest $ .06
--------------------------=-----
Total $19,609.52
2. Type ofAccount Savings Account '
Account Number 15004216657899 I
�
Ownership(Names o,� Kenneth W.Bolze I
Mc�k Bolze(P0,4)
Opening Date 02/20/2008 �
i
�
Balance on Date of Death $ 1,380.28 j
i
�
Accrued Interest $ .02 I
�----------------------------------- i
Total $1,380.30 '
i
I
�
3. Type of Account Safe Deposit Box
Box Number/Location 1083/High Sireet Carlisle
Ownership(Names ofJ Kenneth W.Bolze
Opening Date 08/02/2007
For any additional information on the above accounts,including ownership and any changes,closures and/or reimbursement of funds,
please call the H'igh Street Carlisle at 717-Z40-4536.
T6is letter does not include any accounfs in which the deceased may 6ave been listed as Power of Attomey,Custodian of Uniform Traasfers,
Representative Payee,or Trustee under a Written Agreement
Sincerely,
Valarie Mercer
Adjustment Services
� ' St
�
MEMBERS lst
FEDERAL CREDIT UI IfON
REGULAR SAVINGS ACCOUNT:
Account Number/Suffix 185312-00
Date Account Established 06/29/1999
Principal Balance at Date of Death $25,508.26
Accrued interest to Date of Death $0.42
Total Principal and Accrued Interest $25,508.68
Name of Joint Owner None
MEMBERS 1ST FEDERAL CREDIT UNION
�/ _
Tessa L Klugh
Lending Insurance Support Specialist
May 14, 2014
Estate of: KENNETH W BOLZE
Date of Death: 10/05/2013
Social Security Number: 164-28-2489
5000 Louise Drive • P.O.Box 40 • Mechanicsburg,Pennsplvania 17055 • (800) 283-2328 • wwwmemberslst.org
ROWE'S AUCTION SERVICE
211 N.OLD STONE HOUSE ROAD
CARLISLE, PA 17015
717-249-1978
To: Ronaid E.Johnson, Esquire
78 West Pomfret Street
Carlisle, PA 17013
From: William G. Rowe
Rowe's Auction Service
211 N.Old Stone House Road
Carlisle, PA 17015
Re: Personal Property Appraisal
Kenneth W. Bolze Estate
4 White Oak Dr., Carlisle, PA 17015
Date of Death: Oct. 15,2013
Date: November 21,2013
KITCHEN
Table/4 chairs $110.00
Refrigerator $75.00
Collectibles $15.00
Housewares $20.00
DINING ROOM
Table/4 chairs $105.00
Cupboard $125.00
Miscellaneous housewares $60.00
BEDROOM
Recliner $25.00
Lamp $10.00
Bedroom furniture $65.00
T.V.-no value $0.00
Hunting clothes $15.00
BEDROOM
Bedroom set,3 pc,oak $450.00
Chair $10.00
Lamp $5.00
Sewing machine $5.00
Miscellaneous household $5.00
LIVING ROOM
T.V. $65.00
Lamps $10.00
Vase $15.00
Chair $10.00
Prints $85.00
Sofa $65.00
Miscellaneous household $20.00
Collectibles $15.00
Desk/chair $45.00
Bolze Appraisal 1 11/21/2013
Books $40.00
BASEMENT
Settee $25.00
3-pc upholstery-no value $0.00
Toys $10.00
Bookcases(2) $20.00
Desk $15.00
Seasonal decorations $10.00
WORKSHOP
Cupboard-2 pc $135.00
Ski equipment $20.00
Camping $15.00
Power tools $20.00
Miscellaneous tools $40.00
Hardware $10.00
BEDROOM DOWNSTAIRS
Lamps $10.00
Chair $10.00
PORCH �
Generator $125.00
Patio furniture $45.00
SHED.
Mower $10.00
Ladders(2) $25.00
Miscellaneous garden tools $20.00
GARAGE
Tools $10.00
Snow blower $15.00
Miscellaneous garage $15.00
Kyack, rubber $10.00
HUNTING
Gun cabinet $25.00
Accessories $20.00
Colt 22 cal handgun 149132-2 $225.00
Colt US property 44 cal handgun $375.00
Ruger Black Hawk 44 mag handgun $375.00
Colt automatic 25 cal handgun $125.00
Beretta 22 cal handgun $100.00
Ruger 22 cal handgun $125.00
Winchester Model 12 16 ga pump shotgun $225.00
Thompson black powder 50 cal rifle $100.00
Savage Model 28 12 ga pump shotgun $125.00
J. C. Higgins Model 51 270 Win.w/scope, Belgium $125.00
Ithaca lever action 22 cal rifle $150.00
Double barrel shotgun rabbit ear 12 ga $75.00
Stevens double barrel shotgun rabbit ear 12 ga $75.00
Winchester single barrel shotgun 16 ga $50.00
H&R single barrel shotgun 12 ga $45.00
Smith&Weston 38 cal handgun $325.00
Knives $15.00
Bolze Appraisal 2 11/21/2013
TOTAL $4,765.00
i�
William G. Rowe
Bolze Appraisal 3 11/21/2013 '
REV-1510 EX+(G8-Q9)
� pennsylvania SCHEDULE G
DEPARTMENTOFREVENUE INTER-VIVOS TRANSFERS AND
INHERITANCETAXRE7URN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Kenneth W. Bolze 21-13-1085
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
IiEM DESCRIPTION OF PROPERTY
INCLUDETHENAMEOFTHE7RANSFEREE,THEIRRELATIONSHiPTODECEDENTAND DATEOFDEATH %OFDECD�S EXCLUSION TAXABLE
NUMBER THE DATE OFTRANSFER. ATfACH A COPY Of THE DEED FOR REAL ESTAiE. VALUE OF ASSET INTEREST (IFAPPLICABLE) VALUE
• ... . ...
1� IRA-Pershing LLC as custodian-account no:5HU072962 :
. ._. . _._ _.. . .
Established:October 2004
. , .
Beneficiaries: Annette Sites-100%former spouse
. . ... .... .. . ,
"10/4/13 value$35,930.48
'101713 value$35,765.70 35,848.09 '
_..
2 IRA-Pershing LLC as custodian-account no:5HU072954
_.
:Established:June 1996
..... . ... .. ... .. . .
! Beneficiaries: All sons of the decedent
?Thomas Bolze-33.33%
Mark Bolze-33.33%
,
Victor Bolze-33.33%
:10/4/13 value$138,388.49
. ...... ... ... . . ,....... . .....,. � ...... ,..
1017/13 value$138,085.14 138,236.81 !
'(See statement attached)
_ _.._
TOTAL(Also enter on Line 7, Recapitulation) $ 174,084.90
If more space is needed,use additional sheetr of paper of the same size.
....__ .,_.._..._.
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' ' Page 1 of 2
General(Account#: SHU072962)
Title:�{�q FBO KENNETH W BOLZE RETIREMENT-IRA-ROLLOVER
PERSHING LLC AS CUSTODIAN
ROLLOVER ACCOUNT Home Phone:
4 WHITE OAK DRIVE
CARLISLE PA 17015-9169 Business Phone: (717)486-4586 US Tax ID#: 164-28-2489
Cell Phone: Primary IP#: 59X
Account Registration
IBD#: SVR IBD Name: INVEST FINANCIAL CORPORATION
Primary IP#: 59X Primary IP Name: 7ACQUELINE POWELL
Secondary IP#s: Global One ID:
Master Mnemonic: Acct Mnemonic\Code: MT
Money Manager: Investment Style:
Short Name: BOLZE Old Account#:
Auto Title Build: YES
Account Status: Open(SO/15/2007)
Account Initiated UNKNOWN
Source:
Account Detaiis
Account Type: RETIREMENT Custodian: A-Pershing LLC
Plan Type: IRA Retirement Account Type: ROLLOVER
Plan Admin/Trustee:
Non-Cust Type: Non-Dollar Account: NO
14b1 Objection: Not Objecting Check Writing:
Adop Agreement YES(10/17/2007) Customized Bene NO
Received: Designation Form:
Mutual Fund Only: NO
Purge Eligibie: YES
Link to plan: NO
Tax Residency: UNDOC-PRESUMED US
Institutional/Non-Institutional Account
Institutional/Non-Institutional Account:� Non-Institutional Account
Contact Information
Legal Address: 4 WHITE OAK DRIVE Mailing Address: 4 WHITE OAK DRIVE
CARLISLE PA 17015-9169 CARLiSLE PA 17015-9169
E-mail: Country/State of Residence:UNITED STATES / PENNSYLVANIA
Home Phone: Business Phone: (717)486-4586
Cellular Phone:
General Information
Gender: MALE
Marital Status: SING�E Date of Birth: OS/19/1934(79 yrs old)
US Tax ID Type: SOCIAL SECURITY# US Tax ID#: 164-28-2489
Financial&Employment Information
View Info For: KENNETH BOLZE
Tax Status: EXEMPT
Unidentified Large Trader ID:
Investment Knowledge and Experience
General Investment Knowledge:
Investment Investment Knowledge Since Year(yyyy)
Equities
Options
Fixed Income
Mutual Funds
Unit Investment trusts
Exchange Traded Fund
Real Estate
Insurance
Annuities-Variable
Annuities-Fixed
Precious Metals
https://www2.netxpro.com/accountservices/servlet/AccountDetails Servlet?cmd=profile_g... 10/29/2013
' ' Page 2 of 2
Commodities and Futures
OTHER
Cash&Securities Handling
Proceeds: HOLD Income: CREDIT
Transfer Instructions: HOLD IN STREET NAME Earning Credit Interest: NO
Employment Information
Employer Short Name: Employer CUSIP/Symbol:
Employer Tax ID#:
Employee Relationship:
Employer Name:
Address:
Investment Objectives
Account Discretion:
Comments:
Combined Margin:
MiFID Client Margin Privileges Revoked: NO
Categorization:
Options - Option Limit
Option Account: NO Calls:
Products: Puts:
Trading Level: Total:
OtherInvestments
Are there any other investments:
Time Horizon and Liquidity Needs
Time Horizon: Liquidity Needs:
Related Account Numbers
Brokerage Account#: SpousalAccount#:
Other Account#:
https://www2.netxpro.com/accountservices/servlet/AccountDetailsServlet?cmd�rofile_g... 10/29/2013
' ' Page 1 of 1
Participant/Beneficiary Summary (Account#: 5HU072962)
Title:�R,q FBO KENNETH W BOLZE RETIREMENT-IRA-ROLLOVER
PERSHING LLC AS CUSTODIAN
ROLLOVER ACCOUNT Home Phone:
4 WHITE OAK DRIVE gusiness Phone: (717
CARLISLE PA 170�5-9169 )486-4586 US Tax ID#: 164-28-2489
Cell Phone: Primary IP#: 59X
Account Holder Summary
Name Participant Role US Tax ID# Home Phone Business Phone E-maii
KENNETH BOLZE ACCOUfVT HOLDER 164-28-2489 (717)486-4586
Beneficiary Summary
Name Beneficiary Type US Tax ID# Relationship Gender Date of Birth Allocation(%)
ANNETTE SITES PRIMARY 162-32-2833 OTHER FEMALE 09/15/1943 100
INDIVIDUAL
THOMAS BOLZE CONTINGENT SON MALE 07/21/1963 33.40
MARK BOLZE CONTINGENT SON MALE 06/10/1966 33.30
VICTOR BOLZE CONTINGENT SON MALE 06/10/1969 33.30
https://www2.netxpro.com/accountservices/servlet/AccountDetailsServlet?cmd=participa... 10/29/2013
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General (Account#: SHU072954)
Tit1e:IRA FBO KENNETH W BOLZE RETIREMENT-IRA-ROLLOVER
PERSHING LLC AS CUSTODIAN
ROLLOVERACCOUNT Home Phone:
4 WHITE OAK DRIVE
CARLISLE PA 17015-9169 Business Phone: (717)486-4586 US Tax ID#: 164-28-2489
Ceil Phone: Primary IP#: 59X
Account Registration
IBD#: SVR IBD Name: INVEST FINANCIAL CORPORATION
Primary IP#: 59X Primary IP Name: JACQUELINE POWELL
Secondary IP#s: Global One ID:
Master Mnemonic: Acct Mnemonic\Code: MT
Money Manager: Investment Style:
Short Name: BOLZE Old Account#:
Auto Title Build: YES
Account Status: Open(10/15/2007)
Account Initiated UNKNOWN
Source:
Account Details
Account Type: RETIREMENT Custodian: A-Pershing LLC
Pian Type: IRA Retirement Account Type: ROLLOVER
Plan Admin/Trustee:
Non-Cust Type: Non-Dollar Account: NO
14b1 Objection: Not Objecting Check Writing:
Adop Agreement YES(10/17/2007) Customized Bene NO
Received: Designation Form:
Mutual Fund Only: NO
Purge Eligible: YES
Link to plan: NO
Tax Residency: UNDOC-PRESUMED US
Institutional/Non-Institutional Account
Institutional/Non-Institutional Account:' Non-Institutional Account
Contact Information
Legal Address: 4 WHITE OAK DRIVE Mailing Address: 4 WHITE OAK DRIVE
CARLISLE PA 17015-9169 CARLISLE PA 17015-9169
E-mail: Country/State of Residence:UNITED STATES / PENNSYLVANIA
Home Phone: Business Phone: (717)486-4586
Ceilular Phone:
General Information
Gender: MALE
Marital Status: DIVORCED Date of Birth: OS/19/1934(79 yrs old)
US Tax ID Type: SOCIAL SECURI"fl'# US Tax ID#: 164-28-2489
Financial&Employment Information
View Info For: KENNETH BOLZE
View Info For: MARK BOLZE
Tax Status: EXEMPT
Unidentified Large Treder ID:
Investment Knowledge and Experience
General Investment Knowledge:
Investment Investment Knowledge Since Year(yyyy)
Equities
Options
Fixed Income
Mutual Funds
Unit Investment trusts
Exchange Traded Fund
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� ' Page 2 of 2
Real Estate
Insurance
Annuities-Variable
Annuities-Fixed
Precious Metals
Commodities and Futures
OTHER
Cash&Securities Handling
Proceeds: HOLD Income: CREDIT
Transfer Instructions: HOLD IN STREEf NAME Earning Credit Interest: NO
Employment Information
Employer Short Name: Employer CUSIP/Symboi:
Empioyer Tax ID#:
Employee Relationship:
Employer Name:
Address:
Investment Objectives
Account Discretion:
Comments:
Combined Margin:
MiFID Client Margin Privileges Revoked: NO
Categorization:
Options Option Limit
Option Account: NO Calis:
Products: Puts:
Trading Level: Total:
Other Investments
Are there any other investments:
Time Horizon and Liquidity Needs
Time Horizon: Liquidity Needs:
Related Account Numbers
Brokerage Account#: SpousalAccount#:
Other Account#:
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' ' Page l of l
Beneficiary Details (Account#: SHU072954)
Tit1e:�Rp,FBO KENNETH W BOLZE RETIREMENT-IRA-ROLLOVER
PERSHING LLC AS CUSTODIAN
ROLLOVER ACCOUNT Home Phane:
4 WHITE OAK DRIVE Business Phone: (717 486-4586 US Tax ID#: 164-28-2489
CARLISLE PA 17015-9169 )
Ceil Phone: Primary IP#: 59X
Account Hoider Summary
Name Participant Role US Tax ID# Home Phone Business Phone E-mail
KENNETH BOLZE ACCOUNT HOLDER 164-28-2489 (717)486-4586
Participant Summary
Name Participant Role US Tax ID# Home Phone Business Phone E-mail
MARK BOLZE POWER OF ATTORNEY 168-48-3330 (717)701-8711
Beneficiary Summary
Name Beneficiary Type US Tax ID# Relationship Gender Date of Birth Allocation(%)
THOMAS BOLZE PRIMARY 168-48-3058 SON MALE 07/21/1963 33.33
MARK BOLZE PRIMARY 168-48-3330 SON MALE 06/10/1966 33.33
VICTOR BOLZE PRIMARY 210-52-1010 SON MAIE 06/19/1969 33.34
https://www2.netxpro.com/accountservices/servlet/AccountDetailsS ervlet?cmd�articipa... 10/29/2013
' REV-1S'll EX+ (08-13)
�� SCHEDULE H
�� Y� pennsylvania
�� DEPARTMENTOFREVENUE FUNERAL EXPENSES AND
INHERITANCETAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Kenneth W. Bolze 21-13-1085
DecedenYs debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
i' Ronan Funeral Home 4,294.83
2. Nickel Funeral Home-urn&internment 525.00
3. Rice Memorial-installation of headstone 125.00
e. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions;
Name(s)of Personal Representative(s)
Street Address
City State ZIP
Year(s)Commission Paid;
6,000.00
2. Attorney Fees;
3. Family Exemption: (If decedenYs address is not the same as claimant's,attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: 363.50
5. Accountant Fees;
6. Tax Return Preparer Fees; 325.00
�• Thornwald Home-cable 28.00
s. CenturyLink-telephone 64.34
s. Met Ed-electric 105.79
�o. Comcast-cable 79.04
��. Rowe's Auction Service-personal property appraisal 85.00
�z. Shipley Oil-fuel oil 405.00
TOTAL(Afso enter on Line 9, Recapitulation) $ 12,400.50
If more space is needed,use additional sheets of paper of the same size.
SCHEDULE H- continued
Funeral Expenses,Administration Costs and
Miscellaneous Expenses
ESTATE OF FILE NUMBER
Kenneth W. Bolze 21-13-1085
13. Met Ed-Electric $18.51
14. CenturyLink-telephone $63.55
15. Shipley Oil-fuel oil $405.00
16. Peerless Indemnity Insurance-home&auto insurance premium $466.75
17. Met Ed $61.70
18. Comcast $65.64
19. Mt.Holly Borough-water bill $14.00
20. Scott Ramsey-trash hauling $140.00
21. Shipley Oil-fuel oil $405.00
22. Advance disposal-waste $44.31
23. Met Ed-electric $9.87
24. CenturyLink $40.49
25. Shipley Oil-fuel oil $405.00
26. Met Ed-electric $9.87
27. Paul Davis Restoration-home repairs $500.00
28. Met Ed-electric $4.61
29. Sean Plank-house mowing and maintenance $200.00
30. Prudential Homesale Services-real estate commission $10,495.00
31. Recorder of Deeds-1%transfer tax $1,700.00
32. Carolyn McQuillen,Tax Collector 2014 county/township real estate taYes $410.85
33. American Home Warranty $600.00
34. Borough of Mt.Holly Springs-final water bill(see HIJD-1 attached
To Schedule A for items 25-29) $17.00
35. Reserve for closing and accounting $500.00
Subtotal $16,577.15
TOTAL�a�so enter on���e 9,xe�aP��,�at�o�> $28,977.65
REV-1512 EX+(12-12)
� pennsylvania SCHEDULE I
DEPARTMENTOFREVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Kenneth W. Bolze 21-13-1085
Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
, . ..... ...... _.,._.._ .._..,. .,.... . ..... . ,.., .... _. _.......,
1• Mortgage account no:5132-Orrstown Bank
Principal balance as of 10/5/13 94,838.91
. :
Accrued interest as of 10/5/13(see letter attached0 61.54 ;
2. Thomwald-hair cut expense 16.50
3.: 'Advanced Disposal-trash 44.31 :
4.' Mt.Holly Springs Borough-water bill 23.00
5. 'Goodwill Fire Co-van transport from hospital to nursing home 24.00
6. Cabella's visa account-balance due 406.81 '
7.�' !Comcast-N cable bill 79.04 '
8.` CenturyLink-telephone bill 63.54 !
9.; Shipley Oil-fuel oil bill 405.00 '
10. First United Methodist Church-donation 400.00
11. :Met Ed-electric bill 113.08 '.
' 12. Thornwald Home-final bi 98.23 ''
TOTAL(Also enter on Line 10, Recapitulation) $ 96,573.96 i
If more space is needed,insert additional sheets of the same size.
_ __ _
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��STawN - -.-
��
October 22, 2013
Andrews &Johnson
78 W. Pomfret Street
Carlisle, PA 17013
Re: Kenneth W. Bolze,Acct# 5132
Attention: Ronald Johnson
Dear Mr. Johnson,
As per the letter that you sent to Orrstown Bank, you will fmd the information you
requested for Pennsylvania lnheritance Tax purposes below.
1. Type of account: Mortgage
2. Account number: 5132
3. Names and/or designation: Kenneth W. Bolze
4. Joint account:N/A
5. Date originally opened: 10/13/2011
6. Principal balance as of 10/5/13: $94,838.91
7. Interest balance as of 10/5/i 3: $61.54
If you have any questions,please contact me at the number below or via e-mail.
Sincerely, • ;
,��� i
�
Kayla He dricks
Loan Servicing Specialist '
717-709-3000 ext. 7222
khendricks(cr�,orrstown.com
fax 717-709-3091 '