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Home My WebLink About11-21-14 1505610105 REV-1500 EX(o2-u)(R) OFFICIAL USE ONLY PA Department of Revenue pennsylvania Bureau of Individual Taxes °"""T""°f"`�""` County Code Year File Number PO BOX28o6o> INHERITANCE TAX RETURN f I T Harrisburg,PA 17128-o6oi RESIDENT DECEDENT I ENTER DECEDENT INFORMATION BELOW Social Security Number _ _ _ Date of Death MMDDYYYY Date of Birth MMDDYYYY -_ ^^�w. 09/15/2011� � 11/07/1922 �_ p Decedent's_Last Name_ _ Suffix Decedent's First Name _ MI J Zullinger _ f Chloe___ (If Applicable)Enter Surviving Spouse's Information Below I Spouse's Last Nam_a Suffix Spouse's First Name MI Spouse's Social Security Number - � THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW C D 1.Original Return O 2.Supplemental Return O 3. Remainder Return(Date of Death Prior to 12-13-82) C= 4.Limited Estate O 4a.Future Interest Compromise(date of O 5. Federal Estate Tax Return Required death after 12-12-82) COD 6. Decedent Died Testate C=:) 7.Decedent Maintained a Living Trust _ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) CM 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 TO: Name Daytime Telephone Number Kari inger (717) 234-7828 *� REGISTEF-OF MILLS USE ANLY t'1 C] First Line of AddressIF 13513 North Front Street �r3 Second Line of Address ren DATE JLED City_or Post Office State ZIP Code r' d Harrisburg PA 17110 0 Correspondent's e-mail address: kmellinger@rjmarzella.com Under penalties of perjury,I declare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief, it is true,correct and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNAT E OF PERSON RESE FOR FILING RETURN DATE II ADDRESS 6802 Rice Road, Shippensburg, PA 17257 SIGNAT E O EP R OTHFpR THAN BFPPE ATIVE DATE / ADDRESS 3513 North Front Street, Harrisburg, PA 17110 PLEASE USE ORIGINAL FORM ONLY Side 1 L 1505610105 1505610105 J 1505610205 REV-1500 EX(FI) Decedent's Social Security Number Decedent's Name: Chloe Zullinger RECAPITULATION 1. Real Estate(Schedule A). .............. ... ........................... 1.1 0.00 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.: 199,192.32 6. Jointly Owned Property(Schedule F) O Separate Billing Requested ....... 6. ` 0.00 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested...... .. 7. ; 0.00 8. Total Gross Assets total Lines 1 through 7 8. ' 199,192.32 i i 9. Funeral Expenses and Administrative Costs(Schedule Ft). .................. 9. 23,548.68 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............... 10. j 7,689.68 11. Total Deductions(total Lines 9 and 10).......................... ....... 11.i 31,238.36 12. Net Value of Estate(Line 8 minus Line 11) ............................ .. 12. 167,953.96 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) ........................ 13.; 0.00 l 14. Net Value Subject to Tax(Line 12 minus Line 13) ............. ........ ... 14. ! 167,953.96 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec.9116 (a)(1.2)X.0_ 0.00 15. 0.00 t, 16. Amount of Line 14 taxable at lineal rate X.0 45 167,953 96 + 16. 7,557 93 17. Amount of Line 14 taxable at sibling rate X.12 0.00 - 17. 0.00 18. Amount of Line 14 taxable at collateral rate X.15 0.00 18 0 00 i 19. TAX DUE ................ ......................................... 19.! 7,557.93 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610205 1505610205 REV-1500 EX(FI) Page 3 File Number Decedent's Complete Address: . DECEDENT'S NAME Chloe Zullinger STREETADDRESS 21 Turnpike Road CITY STATE ZIP Newburg PA 17240 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 0.00 2. Credits/Payments A.Prior Payments 0.00 B.Discount 0.00 Total Credits(A+B) (2) 0.00 3. Interest (3) 544.14 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) 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 8,102.07 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.......................................................................................... ❑ 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. 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 surviving spouse is 0 percent [72 P.S.§9116(a)(1.1)(ii)].The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and 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 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 decedent's lineal beneficiaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S.§9116(a)(1.3)].A sibling is defined, under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. REV-1508 EX+(08-12) ipennsyCvania SCHEDULE E low DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN - PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Chloe Zullinger Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. CD Statement-Account#4000031594 49,548.00 2. CD Statement-Account#4000029527 20,386.86 3. Survival Action 119,000.00 4. Pre-Paid Funeral Bill 10,257.46 TOTAL(Also enter on Line 5, Recapitulation) $ 199,192.32 If more space is needed,use additional sheets of paper of the same size. 10/06/2014 15:200rrstown Bank - King St (FAX)717 530 9304 P.001t003 • 1 o�Y OR%RSTOWN BANK Date: 1016/14 From: Theresa A Trace To: Carrie subject: Chloe C Zullinger Estate P: 717-530-2611 Fax Number: 717-234-6883 F: E; Number of ages,Including Cover: 3 URGENT REPLY ASAP PLEASE COMMENT PLEASE REVIEW FOR YOUR INFORMATION COMMENTS:Please call the number listed above If there Is a problem with this transmission. If you need anything else,dust let me know, I Thanks,Theresa ' r CONFIDENTIALITY NOTICEi This facsimile may contain confidential Information,which may be legally privileged, and Is Intended only for the use of the Individual or addressea(s)named above.If you are not the Intended recipient, you are hereby notified that any disclosure,copying,distribution,or taking of any action In reliance on the contents of this transmission Is strictly prohlblted.If you have received this transmission In error,please notify us Immediately by telephone so that we can arrange for the return of the documents at no cost to you,Thank You. www.Orrstown.Coln 10/06/2014 15;200rrstown Bank - King St (FAX)717 530 9304 P,002/003 •`"" TIME DEPOSIT/MA. DA DEBIT ?�,jj,,(,ACCOUNTNTJm5E ,/l'21 1 11Ah a_chirpR `� 6 CUSTOMER NAME TAX YEAR DESCRIPTION S1 PlU MATURS W/D 03 TRA OM TO TRUST JJ NORMAL DIST. PENALTY AMOUNT 04 PAMa.Y SMBROENCY 57 INT.TRANsmR OUT 0 p ss ma,TRANSFER OUT NEW BALANCE AUs'I'O DBATI{ i8R INSTTI'UTI0N 08 DISSATWIM W1 BANX RATE CUSTOMER SIG A 00 Spw FUNDS WWRIN OB 10 NO CODS PROVIDED AY 13RANCH PREPARED BY WITFIDRAWAL AMOUNT 1: 500 Lill 70001: 4 2 24 LOIl' >031315036< Orratown Bank ShiDDensbu=q, 2A 17257 Phone: 717-532-6114 Bun Date: 02/13/2012 Branch/Teller 0003/0046 02/13/2012 11:35:17 10/06/2014 15;200rrstown Bank - King St (FAX)717 530 9304 P.003/003 TIME DEPOSIT/MA DATS DEBIT � �I��A C NUMBER CUSTOMER NAME TAX XSAR�..� DESCRIPTION REASON COI)_: COD 0 ' 19 51PREMATURE W/D PENALTY AMOUNT `� 31 N01MAL DIST. 57 � ER OUT 04 FAMILY EMERGENCY 59 EXT.TRANS OUT N NEW BALANCE TQ swTH EmP.1NSTTI UTION CU810Iv1ER 3IONAT 03 DISSA=FMD W/BANK RATS 09 SPLrr FUNDS WTMIN OD 10 NO CODs PROVMM BY BRANCH PREPARED BY WITHDRAWAL AMOUNT $ 010 $lo 1:50011,170001; Le 2 23 10n, >031315036< Orrstown Bank Shippensburg, PA 17257 Phone; 717-532-6114 Bus Date: 02/13/2012 Branch/Teller 0003/0046 02/13/2012 11:38:17 pennsylvania DEPARTMENT OF REVENUE November 13, 2013 Robin Marzella,Esquire Law Office 3513 N.Front Street Harrisburg,PA 17110 Re: Estate of Chloe Zullinger File Number 2111-1057 Court of Common Pleas Franklin County Dear Attorney Marzella: 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 88 year old decedent died as a result of a motor vehicle accident. Decedent is survived by her two daughters. 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, $178,500.00 to the wrongful death claim and$178,500.00 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 Merry, 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. I ly,n E.Baker Trust Valuation Specialist Inheritance Tax Division Bureau of Individual Taxes PO Box 280601 Harrisburg, PA 17128 1 717.783.5824 1 shabaker@pa.gov Date September 26, 2011 ci No. Funeral of Chloe C. Zullinger co 14rs. Nancy A. Swope (0 To 6802 Rice.Road co Shippensburg, PA 17257 C.0 N Personal,Staff and '(A) Serviced,including merchandise....................... Professional Services Funeral Home Facilities and Squipment $5,350.00 Automobile Equipment Casket $2,480.00 Interment Receptacle $ 1,200.00 Monument Engraving $ 150.00 Direct Cremation (B) Cash Advanced. Total W $9,180.00 We have advanced the following funds Grave Opening $ 400.00 for your convenience.............—........................ *Newspaper Notices 0 329.35 *Public Opinion $135.00 Clergy Honorarium $ 75.00 Sentinel $144.35 Certified Copies $ 90.00 News Chronicle $50-00 Flowers $ 202.46 0 Organist Honorarium $ 75.00 U) $1,171 .81 co Total'13' 0- E (C) Additional items,orderf d later.......................... *$9,405.97 paid by Homesteaders Life 'Company Total ICI 00 $751 -49 discount on services Complete Total 10 351 .81 9 *W:257 .46 $100.00 to be paid by Cumberland County Veterans Affairs Due Ocit, 30, 2011 Amount Paid C3 C) payable to Fogelsanger—Bricker Funeral Home Balance $ 94 .35 o F-4 Balance - Sentinel & News Chronicle less VA benefit Apr 03 00 01:08a First Impressions 717-261-2866 p•3 PRENEED FUNERAL AGREEMENT AND ASSIGNMENT EXHIBIT 1 — STATEMENT OF FUNERAL MERCHANDISE AND FUNERAL SERVICES NOTE: THIS AGREEMENT IS TO BE FUNDED BY THE ASSIGNMENT OF INSURANCE BENEFITS FORTHEBENEFITOF (Funeral Recipient/Insured) (Address) (Phone) IN AGREEMENT WITH AND ASSIGNMENT TO (Funeral Provider Dame) GUARANTEED PROFESSIONAL SERVICES GUARANTEED MERCHANDISE Services of Funeral Director and Staff $ Casket $ Embalming(See Agreement and Below*) $ Manufacturer Other Preparation $ Model Name Visitation Days at$ /Day $ Model Number Funeral Ceremony/Memorial Service $ Other Use of Facilities and Staff(Specify) Exterior Description $ Interior Description Transfer of Remains to Funeral Home $ Outer Burial Container $ If beyond a mile radius, which is our service Model Name area,there will be a charge of$ per mile one way. Model Number Family Car(s) at$ each $ Limousine Hearse $ Manufacturer Cremation $ Constructed of - Forwarding/Receiving Remains $ Other Guaranteed Merchandise(Specify) Other Services/Facilities/Equipment(Specify) $ TOTAL GUARANTEED SERVICES $ TOTAL GUARANTEED MERCHANDISE Is NON-GUARANTEED CASH ADVANCES Death Certificates at$ $ Escort $ Flowers $ Grave Opening and Closing $ Music- $ Memorial Cards/Book $ Honorariums S Clothing(Specify) $ Obituaries $ Monument/Marker $ Hairdresser $ Engraving $ Shipping Container $ Other(Sped}y) $ Other(Spec) $ $ We charge you for our services in obtaining: TOTAL NON-GUARANTEED CASH ADVANCES $ TOTAL GUARANTEED AND NON-GUARANTEED FUNERAL PRICE $ `REQUIRED PURCHASES--Charges are only for those items that you selected or that are required.If we are required by law or by a cemetery or crematory to use any items,we will explain the reasons in writing below. EXHIBIT 1 ABOVE AND THE PRENEED FUNERAL AGREEMENT AND ASSIGNMENT ON THE REVERSE SIDE SHALL CONSTITUTE THE TERMS AND CONDITIONS OF THIS AGREEMENT. AGREEMENT AND ASSIGNMENT BY: AGREEMENT.AND.ACCEPTANCE BY: X X _ (Signature of Purchaser) (Date) (Signature of Provider's Authorized Representative) (Date) (Address) (Phone) (Location) (Phone) (City,State) {Zip) (City,State) (Zip) HOME SALES ONLY: You, the Buyer, may cancel this transaction at any time prior to the third business day after the date of this transaction.See the attached Notice of Cancellation form for an explanation of this right_ P001-A CHLC,1995,AC rights reserved.No use or reproduction without express permission. Rev.03/10/95 Copies:Original—Homesteaders Life Company;Pink—Provider;Canary—Purchaser X-Ge REV-1511 EX+ (08-13) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Chloe Zullinger Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' Funeral Bill (10,3511.811 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: 9,959.62 Name(s)of Personal Representative(s) Nancy Swope Street Address 6802 Rice Road city Shippensburg State PA zip 17257 Year(s)Commission Paid: 2014 2,595.00 2. Attorney Fees: 3. Family Exemption:(If decedent's address is not the same as claimant's,attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 642.25 5. Accountant Fees: 6. Tax Return Preparer Fees: 7. TOTAL(Also enter on Line 9, Recapitulation) $ 23,548.68 If more space is needed,use additional sheets of paper of the same size. r, TIME SHEET—The Estate of Chloe Zullinger 9/23/11 RJM Convo with Clark .1(6) 9/23/11 RJM Convo with client .1(6) 9/32/11 RJM Phone Call—Orrstown Bank .1(6) 10/7/11 CVS Raised Estate 1.5(lhr30min) 10/7/11 RJM Sent tasks to JRH .2(12) 10/13/11 RJM Letter to Metzger— Short Certs. .1(6) 11/9/11 RJM Phone Call about CD's .2(12) 11/10/11 JRH Proof of Pub .5(30) 11/10/11 RJM Sent notices to beneficiaries .8(48) 11/10/11 RJM Sent Notices to ROW .2(12) 1/15/12 CVS EIN Form .2(12) 1/4/12 RJM Letter/Checks to Metzger .1(6) 1/26/12 RJM Call to Orrstown Bank .1(6) 2/3/12 RJM Phone Call with Client .4(24) 2/7/12 RJM Called Heather .1(6) 2/8/12 RJM Overnighted checks to Orrstown .6(36) 7/16/13 CVS Status Report .2(12) 8/28/13 CVS Call to Sandy Andrews .1(6) 8/28/13 CVS Call to daughter regarding mother .4(24) 8/28/13 CVS Review petition .4(6) 8/29/13 RJM Status Memo/Update .2(12) 9/5/13 CVS Called PR for funeral bills .2(12) t 9/5/13 CVS Letter to Baker regarding split 1(Ihr) 10/11/13 CVS Letter to Dept. of Rev—Allocation .6(36) 12/3/13 CVS Spoke to client .2(12) 12/18/13 RJM Spoke to fain. About tax return .3(18) 1/2/14 RJM Fax to Metzger-Invoice .1(6) 2/10/14 RJM Letter from Metzger .1(6) 2/19/14 RJM Medicare Letter .1(6) 3/4/14 RJM Erie reimbursement letter .1(6) 3/25/14 CVS Met PR's to give them check 1.3(lhrl8min) 3/25/14 CVS Spoke to PR's about money .2(12) 3/25/14 CVS Spoke to bank—Account Balance .2(12) 4/3/14 CVS Spoke to client—Account balance .2(12) 4/3/14 CVS Called client—Left message .1(6) 4/10/14 CVS Provided check—Chambersburg 1.3(1hrl8min) 4/15/14 CVS Letter to Client—Enclosed check .1(6) 4/16/14 CVS Status Report .3(18) 6/17/14 NM Letter to ROW .1(6) 6/18/14 NM Called Court .2 (12) 6/18/14 NM Request Proof of pub .2 (12) 7/10/14 KEM Phone Call with Client .1(6) 7/16/14 KEM Start Inh Tax Ret .5(30) 8/20/14 KEM Phone Call with Client .1(6) 8/26/14 NM Rec'd missing Proof of Pub. .1(6) 8/27/14 KEM Inh Tax Ret 1.3 (1hrl8min) 9/15/14 TLS Phone Call with Client .2(12) 10/3/14 KEM Status Report .2(12) 10/6/14 TLS Status Report .2(12) 10/6/14 TLS Letter to Client .1(6) 10/8/14 KEM Phone Call with Client .2(12) 10/20/14 KEM Inh Tax Ret .6(36) Pending KEM Fam. Settlement. Agreement 1(lhr) Pending KEM Final Stat. Report .1(6) TOTAL HOURS: 18.1 hours 16.5 hours X $150/hour TLS = $75/hour $2, 475 NM= $75/hour JRH= $75/hour KEM= $150/hour CVS = $150/hour 1.6 RJM= $150/hour X $75/hour $120 TOTAL COST: $2,595 REV-1512 EX= 2-'_5, i pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Chloe Zullinger 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. Medicare Lien 7,689.69 TOTAL(Also enter on Line 10, Recapitulation) $ 7,689.69 If more space is needed, insert additional sheets of the same size. CC}B►R' Coordfriallon of CCENTMSFORMII)ICA%ELMEDICMSMVICES Benefits and Recovery February 19,2014 293 1 MB 0.435 ***AUTO*"MMD AADC 720 R:293 T:6 P:6 PCJ F:359201 ME7ZGER&WICKERSHAM PO BOX 5300 HARRISBURG,PA 17110-0300 Jill till I IIIIIIIII IIIIIIII III 111 1111111111111111 Beneficiary Name: CHLOE ZULLINGER og Medicare Number: 203108436A Ok Entitlement Date: July 01, 1973 C, Date of 0 Incident: September 14,2011 C2 0— Case Identification Number: 201206709000144 DCN: 10021014-0009511 0 Dear METZGER&WICKERSHAM: We have received check number 0000378321 in the amount of$7,689.69. This amount has been applied to the outstanding debt due Medicare. The principal amount of the debt and interest(if MMMM�— applicable)has been reduced to zero and our file is being closed. If a refund is due it will be processed and forwarded to the appropriate party under separate cover. If the original check submitted to Medicare had multiple payees it will be the attorney and/or beneficiary's responsibility to disburse the funds to all other payees. If you have any questions concerning this matter, please contact the Benefits Coordination & Recovery Center (BCRQ by phone at 1-855-798-2627 (TTYITDD: 1-855-797-2627 for the hearing and speech impaired),in writing at the address below,or by fax to 405-869-3309. When sending -- ondence, please include the Beneficiary Name along with the Medicare d Case correspondence, an Numbers (shown above). NGHP • P.O.Box 138832 • Oklahoma City,OK 73113 ML001NGHP REV-1513 EX+(01-10) pennsylvania SCHEDULE J ... DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Chloe Zullinger 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 and transfers under Sec.9116(a)(1.2).J 1. Nancy Swope Daughter 50% 2. Sandra Anderson Daughter 50% ENTER DOLLAR AMOUNTS FOR DISTRI8UTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II—ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ONLINE 13 OF REV-1500 COVER SHEET. $ If more space is needed,use additional sheets of paper of the same size. PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16, 1929), P. L.1784 COMMONWEALTH OF PENNSYLVANIA : ss. COUNTY OF CUMBERLAND Lisa Marie Coyne,Esquire, Editor of the Cumberland Law Journal, of the County and State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid, was established January 2, 1952, and designated by the local courts as the official legal periodical for the publication of all legal notices, and has, since January 2, 1952,been regularly issued weekly in the said County, and that the printed notice or publication attachedhereto is exactly the same as was printed in the regular editions and issues of the said Cumberland Law Journal on the following dates, viz: July 11, and July 18, 2014 Affiant further deposes that he is authorized to verify this statement by the Cumberland Law Journal, a legal periodical of general circulation, and that he is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the:foregoing statements as to time,place and character of publication are true. 6,4r isa M rie oyne Editor SWO TO AND SUBSCRIBED before me this 18 day of July, 2014 r Notary Zullinger, Chloe, deed. Late of Hopewell Township. Executrices: Nancy Swope, 6802 Rice Road, Shippensburg, PA 17257 and Sandra L. Anderson, 425 Bacun Road, McConnells !.I>dOt•!WEALTH OF PENNSYLVANIA la burg,PA 17233. a NOTARIAL SEAL Attorneys:Robin J. Marzella,Es- DEBORAH A COLLINS quire,R.J.Marzella&Associates, Notary Public 3513 North Front Street, Harris- CPRLISi.E BORO.,CUMBERLAND CNTY burg,PA 17110. ; Wy Commission Expires Apr 28,2018 PROOF OF PUBLICATION State of Pennsylvania,County of Cumberland Patrick Doane,Production Director, of The Sentinel, of the County and State aforesaid, being duly sworn, deposes and says that THE SENTINEL,a newspaper of general circulation in the Borough of Carlisle,County and State aforesaid,was established December 13th,1881, since which date THE SENTINEL has been regularly issued in said County,and that the printed notice or publication attached hereto is exactly the same as was printed and published in the regular editions and issues of November 18,2011 and November 25 2011 and December 2,2011 COPY OF NOTICE OF PUBLICATION ESTATE NOTICE ESTATE OF: CHLOE ZULLINGER LATE OF: Hopewell Township,PA, Affiant further deposes that he/she is not Cumberland County September 15,2011 interested in the subject matter of the DIED: aforesaid notice or advertisement,and that EXECUTOR/ADMINISTRATOR: 6602 A ce Road all allegations in the foregoing statement as Representative's Address: Shippensburg,PA 17257 Sandra L.Anderson to time,place and character of publication EGU...G3BlA.... 11Auad::.:r' .......:::::::::::.::. x .. .... :::................._;_................_........... EX B�c1c7U 11� f Represehtativb` �..:.,�... .. McConnelsburg;PA'T7233-•-•---- r, ATTORNEY: Robin J.MarMahe&A Esquire o--- r R.J.Marzella&Associates Attorney's Address: 3513 North Front Street Harrisburg,PA 17110 ..._................................................................................_._................._.........._............................_....-.._.........................................._ _.....-.. .._ ................. Sworn to and subscribed before me this 15"' clan .II 1u, m t 4 Notary Public My commission expires: COMMONWEALTH OF PENNSYLVANIA Notarial Seal Bethany M.Holtty,Notary Public Carlisle Boro,Cumberland County My Commission Expires Sept.26,2015 MEMBER,PENNSYLVANIA ASSOCIATION OF NOTARIES 1:45 PM R.J. MARZELLA, ESQUIRE AND ASSOCIATES, P.C. 10/20/14 Account QuickReport Accrual Basis All Transactions Type Date Num Name Memo Split Amount Client Prepaids RJM'S Zullinger, Est Chloe Check 02/08/2012 19670 Federal Express Bank(M&T) ... 22.52 Check 05/01/2012 19799 Patriot News Bank(M&T) ... 249.57 Check 05/01/2012 19805 The Sentinel Bank(M&T) ... 232.02 Check 06/05/2012 19936 Jacqulyn Harris Bank (M&T) ... 21.73 Deposit 02/10/2014 Deposit Deposit Bank(M&T) ... -525.84 Check 04/18/2014 21482 Cynthia M Von Sc... Bank(M&T) ... 41.41 Check 05/15/2014 21541 Cynthia M Von Sc... VOID: Bank(M&T) ... 0.00 Check 09/12/2014 22206 Cumberland Law... Zullinger Es... Bank(M&T) ... 75.00 Total Zullinger, Est Chloe 116.41 Total RJM'S 116.41 Total Client Prepaids 116.41 TOTAL 116.41 Page 1 LAST WILL AND TESTAMENT 1, CHLOE C. ZULLINGER, of R. D. 1, Newburg, Cumberland County, Pennsylvania, being of sound mind, memory and disposition, do hereby make, publish and declare this my Last Will and Testament, hereby revoking and making void all wills by me at any time heretofore made. FIRST. I order and direct the payment of all my Just debts and funeral expenses as soon as may be convenient after my decease. SECOND. I give, devise, and bequeath all my estate, real, personal, and mixed, whatsoever and wheresoever situate, to my beloved husband, WARREN V.. ZULLINGER, absolutely. THIRD. In the event that my said husband predeceases me or we die as the result of a common distster, I then give, devise, and bequeath my said estate to my daughter, SANDRA Z. ANDERSON and to my daughter, NANCY Z. SWOPE, share and share alike. FOURTH. I nominate, constitute and appoint my husband, WARREN V. ZULLINGER, to be the Executor of this my Last Will and Testament; and if he be unable to fulfill the duties of Executor, I then nominate, constitute, and appoint my daughters, SANDRA Z. ANDERSON and NANCY Z. SWOPE, to be my Co-Executrices. IN WITNESS WHEREOF, I, CHLOE C. ZULLINGER, have hereunto set my hand and seal to this my Last Will and Testament this l J day of 1976. d Lze (D-1 (SEAL) Signed, sealed, published and declared by CHLOE C. ZULLINGER, the Testatrix, as and for her Last Will and Testament, in the presence of us who have, at her request, signed our names as (7) r in Hic, nrpqpnrp POWER OF ATTORNEY AND FEE AGREEMENT We,Nancy Swope and Sandra Anderson, as co-executrix of the Estate of Chloe Zullinger,have asked R.J. Marzella&Associates,P.C. to represent me in connection with: The probating of the Chloe Zullinger estate. We, R.J. Marzella&Associates, P.C., accept this engagement on the terms set forth below: 1. You understand that in no event does our role in undertaking this engagement include transferring any aspect of this matter to any federal court, or appealing any aspect of this matter to any appellate court. 2. We will endeavor to keep you informed by sending you copies'of significant , papers we prepare or receive in connection with this matter. In addition, we will be available to you by telephone or in person for consultation. If no one is available when you telephone, your call will be returned within a reasonable time under the circumstances. 3. Our hourly fee for this engagement is at a rate of$150.00 per hour, to be due on a monthly basis. 4. You understand that a one and one-half percent per month service charge will be assessed by our firm on any bill balance that remains unpaid for more than thirty(30) days after the date the bill has been sent. We expect and require prompt payment of the bills our firm sends you, and we reserve the right to terminate the attorney/client relationship if you should fail to pay those bills on time. We also reserve the right to terminate the relationship if you insist upon pursuing or ask us to help you pursue an objective or engage in a course of conduct that we consider repugnant or imprudent or with which we have a fundamental disagreement. You, as the client,may terminate the attorney/client relationship with us at any time, of course, but if you wish to do so,please do so in writing. In the event of a termination,whether by client or by attorneys, client agrees to,upon request,promptly sign a Praecipe for the attorneys to withdraw their appearance in any litigation and/or Praecipe for the client to represent himself/herself,pro se, in any litigation. In event of a termination of our services while money is still owed,you understand that you are responsible to pay our fees incurred to the date of termination and you will so inform any future attorney that you still owe us fees. In the event that the Client(s) seek(s) legal representation elsewhere regarding the incident described herein and after the instant Fee Agreement is executed, Client(s) agrees to immediately reimburse Attorney for all expenses incurred to date. Moreover, for the work performed by the Attorney up to the date of separation of Attorney and Client(s), Client(s) agree(s)that, in the event of an ultimate monetary recovery, Attorney is entitled to reasonable compensation(quantum merit) from any verdict or settlement. 5. You agree to bring to our attention any questions you have about any bills our firm sends you within thirty (30)days of the date of those bills. You will not be charged for any time we spend with you on the telephone or in person discussing our firm's bills to you. Further, you agree that any monies we may receive on your behalf as a result of settlement, court order, or otherwise,may be used by us to pay any amount you owe us at that time. 6. In the event of any disagreement concerning this attorney/client relationship, this fee agreement, and/or for the client to bring any action against the attorneys for negligence or any other kind of action,both parties agree that any unresolved disputes or issues arising out of the Firm's representation of the Client(s) in this matter will be submitted to mandatory, binging arbitration with a certified Christian conciliator. If a dispute arises, the Firm will provide the names of the arbitrators. The Client will select one who will act as the sole arbitrator. Judgment upon an arbitration decision may be entered in any court otherwise having jurisdiction. The parties understand that these methods shall be the sole remedy for any controversy or claim arising out of this agreement and expressly waive the right to file a lawsuit in any civil court against one another for such disputes, except to enforce an arbitration decision. 7. The foregoing should not be construed to prevent the attorneys from suing the client to collect any undisputed fee or portion thereof. 8. You understand that you are engaging this law firm and that a firm attorney other than the attorney who initially met with you or who was initially assigned to work on your case may appear at hearings or perform work for you on your case. 9. It is our understanding that you have authorized us to communicate freely with Yolanda Feliciano concerning all aspects of your case with us. We will continue to do so until we hear differently from you in writing. This agreement shall become effective and our representation will commence upon our receipt of a signed copy of this letter. Please execute a copy of this Agreement where indicated below and return it to us with payment of our fee and we will then commence working on the case. You understand that until you have signed this Agreement and paid us the fee, we have not been hired and we will do no work on your case. Of course, if you have any questions on this agreement,please ask us before you sign and return it to us. 2 WE,NANCY SWOPE AND SANDRA ANDERSON,HAVE READ THE ABOVE AGREEMENT AND UNDERSTAND AND AGREE TO ITS TERMS. THERE ARE NO OTHER AGREEMENTS BETWEEN THE PARTIES HERETO PERTAINI/N�GG TO THIS MATTER. THIS AGREEMENT IS ENTERED INTO THIS _ DAY OF /i T L- 2014. NANO SWOPE J DATE ANDRA ANDERSON DATE CYNTHIA M.VON SCHLICHTEN,ESQUIRE R.J.MARZELLA&ASSOCIATES,P.C. 3