Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
02-1097
CUMBERLAND Register of Wills of County, Pennsylvania PETITION FOR GRANT OF LETTERS Estate of Jean G. Jordan also known as Veo[ione~lsl, w ; , e 72 years of age ac older, apUfYliaa) tor: (COINIPLETEy°A" OR "B°' BELOW) Deceased No. ~;~-0.1 -/04} Social Security I`ao, 146-18-8758 `a~~ A. Probate and i~rant of Letters and aver that Petitioner{s) is/are the execut or nymed in the Las; ~r~r;i of t he `~' Decedent, dated December 19, 1997 and codicil(s) dated R[a[e relevant cirwmstences, e.g., renunciation, dean of executor, etc. Ex;:apt as foi?ows, Decedent did not marry, kvas not divorc+:d, and did not have a child born or adopiad after execution of the doc~_n:ents offered for prooate; vvas not the victim of a killing and ~~Yas never adjudicated incompetent: 8. Grant of Letters of ,4dministration e.t.a.. d.n.n.ar.a. r,eoden[e u[e; au,oo[e aeee„sa..;„pant,: n,~„o,~ra~e~ Petitioners) after a proper search has/have ascertained that Decedent left no Will and was survived by the foilo+rvng spouse (if any) and heirs: Decese;l'i ar death owned property avith estimated values as foilo+rvs Uf ~i.~;tn;pi;es ir. P,~,! A!'s personal arcperty ~ rj ~ 0 ~ {if not domiciled in PA.; Personal propert+~ in Penrlsyivarlia .. . . . ................. _ --v`1---- (!f n,~i clomicied in P~) Persona! properly in County ............. . ............ $ --- 'value of real estate in Pennsylvania ........ ......... .......... ............ .. .. _ ~~- - ---- Toxa1 ...... - Real Estate si+.~_eafiad as foll.ovv~: ................. ......... ........................... S---G_S ~ ~~- -_- dr_ c^re~Ji eYi (-- +.''`h f i!enet,~) respect#:~Ih~ re nest(s) the p~c~ara of the last'NiN ar~,~a C~.,~!ICl{Isl prflsartad ~;vith i~~i~ i'~~li!_n any tie gfa~t ~. ~~ ,_, , , apprcpna_,. forte, ro the unde;signad: . t l / ~ Sign~t+..fre Type:J or p-inted nee;-~e ar~d rasi~'enc~ I /7 ~ C 1808 Signal Hill Drive Mechanicsbur PA 17050 f __ ___ ~ I 1 _ ~ rv , ,~_----- Doredent tivas domiciled at death in _Cumberland __ County, Per,nsylvani~, ~Jith hisiher last farniiy or principal residence at_ Claremont Nursing Home, 1000 Cla_remont__Road, Carlisle PA .17013 _ _~ - ,1,5[ 9ttee,. n„rn~e~ and tn„n~~.i~~l[,1 ~ /~~eleJ ~eSe~c TW ~ Decedent, .then 78 years of age, died NOVember 23 _, 2G ~? at Carlisle, PA Oath ofi Personal Representative Commonwealth of Pennsylvania COUnty Of CUMBERLAND The Petitienerls) above-named swear8s) and affirmts) that the statements in the foregoing Petition are true and Lorrect to the best of the knowledge and belief of Petitio 1sD and that, as pe nai representativeis) of the DecedRnt, Petitioner{s) irvili wel! and truly administer the est error in ~o taw ' \~ Sworn to and affirmed and subscribed _ before me t1i 3 r_ d day of L~ECF.7n13ER 20 0 2 20 DECREE OF PEGlSTEB Estate of __ JEAN_G JORDAN _ ~ Deceased Nfl. __~1-02-1092 a150 ~CnflL^/r3 a5 -- -- Soria! Security I'J;;: 146-18-8758 Data of Death; 11-23-2002 _ A;'JO ~J011L', DECEMBER 5, 2002 20 in cansi~era#ion of tt~e Petition nn t)i~ rAverse si{)e hereon, satisfiac#ory ~rcof havintd been Qresented before rne, ! ;° !S ~~~~.~?SI=D that Letters ^ Testamentary C1. of ~idrninistratifln TESTAMENTARY~_~ ~.. e.; J.t~ i~.~. t ~_n<1rr,:e I~.. ,, V~iiante 3t>>...i Jur:,n i.~ ~,.~.~ur t.~r..i are hereby ~; anted to JOHN S JORD in the a)~O~t~e estate and that the instrurr~ent,s), if any, dated WILL: 1z-19-1997 ~lescri~:~ed In file PetitiOr~ be a~r~itted to ~~r~bate and f;1~;~! of rees~r~ a3 the last 'vv'i!i cif ~ececier~t. FEES Le##ers ......................:.... ~ 60.00 - uhcr i t/ertifica#e;s).....,.... ~ 15.00 Extra PaOas { ),,..,..,..,, ~_ 6.00 Codioi :....... .................. a _ ~i~~P ree ........................ ~ 10.00 L l?ven#`,->, ~.~ Tax or;~s.,. Cth~r ... ..... .............:.... S TOTAL ...........:.... ~ 91.00 ~'ri-. Att~~rr~~~y~: .~ddrt,,~~. Teieph~,ne:_ SAT;; ElLED Ra~ist~r of 'J4'~.'.`s Ste n J. Schiffman 25488 208G Linglestown_Rd., Suite 201 Harrisburg, PA 17110 (717) 540-9170 1 ~- 5- o ~ ----- ---- ~la~.Q,~ ~ ~ 1a.-5-off his is to c°rrif~~ that t(ie information h~rc given ss 1_':~Irr~tl~y' t'., ,_ ,(_ ,; local fdegisrrar. The origina; certificate will 1;e totwar~{mod tr. ,-"~ - "~ WARNING: It is illegal ~o ~~~+iica~~ t~i~ sl:,.~f=, ~~ ~~° ~~,~ ~~ ~~ t.~~, , , 1 ••e for this ct Itil:;re, ~i.?.UU __P 8777519 . ,., ~,e, rnr YPF YIIINI ~N 'ENM4NGN1 BLALKIN ~.~.~~ " 1 ,a ~~ ; L '` ~- 3~~ p ~ . .r. -w ~ , ~~~ _.; .O: ,\ iA - - `/ G9~~~/ /~~-ccezy o~ 7 e2~ c ~ COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH K __ ~. ..._. ... _~....._~ ___ SE% SGGUL SECURITY NVMBER __-_..__ __ __ ___ _ _____ DALE OF GEATH,MCnm. Lay. .w -~- 1 3f cyfs 3•o RD ox4 :. ~cm~.l~ a. l`16 - 18 - 'al a. AGE ~ Est Bnmoayl UNDER (YEAR - S 8 a. 11 ~'I ~ I Q Z UNDER t DAY DATE OF BIRCH BIRTHPLACE ICny and PLACE OF DEATH Ifneck only one -- tee mmr .e n ~-.L M w w~a nn p e~ y~dnt onlhe r Daya Mourn ( Mkwlp ~MOnIn. DaY • 1 ilalew icregn ~ounli Yl HOSPITAL ---- y ' I OTHER: ~ ---'-'- ~ oZ~,Z/a4 T Ph~11Ptf.G PII,A Pa Inpalianl^ EWOMparam ^ OIDA^ "u^xp OIWr -- -- e Home ~~ , . Rea4e^u 000NTVOFDERH C,TV BORO.TWP OF DEATN FACILITY NAME p. ,Sralc,ryl l_~ ju not mv~luuun gwe slreM antl numbmi . WAS DECEDENT OF HISPANIC ORIGIN? RACE ~ Amsr¢an Inman, &ack, wna. arc. C um Q >: 2l a n~ CaLR 11 s 1,~ No Cd w, ~ X yp. apacAr cw.n. ISp«Mr an. rk C~O~~L MOnI NU.fSync ~ R~:h~B eels Me+KS Pwno RK . , . an, ac. Wit \I 1- DECEDENT'S USUAL OCCUPATION ~ E __ KIND OF BUSINESSIMDUSTRV ' 19. NMS DECEDENT EVERM DECEDENT'S EDUCATbN IG~ve x~dofwwktlone duringrroy US ARMEDFORCESt MARITAL STATUS~Marned SURVIVING SPWSE of wwkinU li,e, p not use re( ed 1 (-y S ' oM n' 651 cam ad Never ManiM, Witlpwed. Uwe maaWn nYnel ,p wda Nm m . fDry"; ; eery ° Q`(U (Z $ \ 011.9. OiYarced ISpx~ryl vas ._ No NJ n.. (1 G - ME~icox.l l,..a B.l ,:. ,a. ~ ,m. ,. DlwotzcCil ---- DECEDENT'S MAILING ADDRESS S . ( lrpl, CSy/bwn,SMN.Zp Copl DECEDENT'S ,~~ ACTUAL , 7a. Sh,e~Qi rr,, 1Te.L1 Yp o f m l3E 2 D 2 i V.R dacapAlivsd in IDZ N ~ ~ , . RESIDENCE a _ ~ icepn ISee mvrucluln4 f n• C Um E-l'1 \ 1 Q 0. on we - ,~. 1 1 011 er sldel Ctn R F (M~ mwnanip? No, dse.e.r%kv.d Ce.M P E1.11 ,TD. cnw,ry n 2 n (~ ` _ a. walun anr,r Irma a. ___ fATMER'S NAME IFas1. Middle. Lawl la. GFo (~6~ ~raRCfS (^j a-[jE2 ____ ceY•LOrO MOTHER'S NAME IFast. M~dde. Maitlen $umamal INFORMANT NAME ITypD'Prm9 ,a.Ma(ZGyA2E~ Co 2T WY2~6 (•lT SI'o L~~ ' SMAILINO ADDRESS ISIreel. Ciry/i ,$YIe. Zip COdel ~Cj 1\(`/ S INFORMANT zW So 2eo ty . . z9D.l8oa Sic (so1L {{~1( Drz~V.a~. YYtF.ehcull~,(3L.r Pc METHOD Of DISPOSI710N D 7~0~0 T _ A E OF DISPOSITION PLACE OF DISPOSITION-Hama MCsmarery, Crematory LOCATION-CM/T .SIa1a, Zp Cop Bunal ~~ Cremation LJ q.mpvM tram BIM. LJ (MOnlh, DaY Haar) orpMr Plx. ' wn.Ian (. ] aner Ispnc~Nt C ala_ 9,D. 11~.?G ~Z x,e, ~«rr ,`IaR21S'<3~V'•. CFMAT3 C'' SIGNATURE F ~G22l L a S ne. ,^~ l _ UNERAL SERVICE LK:ENSEE RSON ACTING AS SUCH LICENSE NUMBER (_(IVR NAME ANDAODRESS OF FACILITY NFiI L ` ( U9fl`Ct ~t~11.P+.f- o-•~ ~ ~lu /,aAy zb. ~~c19cE4-~.- n`. uD 3 . Complete`, ms 23a<on1 wfwn nl -. 2zc. O/ m0.2 f7 ST ~n~ ~y// ~ /7/../ Y ryug ~ IW Dp1 yhrowMdge. death occurred al lhsu dale and Vlace sla ed n V YS~cun ~ rot ava~Mdtl al Ilme of path b ($iUnalwe Ti o) LICENSE NUMBER DATE SIGNED unify Cdu of paM , IMw~m. DaY "earl /~/V '.3,S3dJ ~/- L // /a~j/U:oj 'aa' ~ a,, o6m54d-z6m lW l . us omp C IedD e y TIME OF Tlt.v._ DATE PRONOUN ED EAO I won, Da .Year zk. parson woo pronounces pmh. ~ Y J 1 VMS CASE REFERRED TO MED I CAL E%AMINERICORONER7 , ~( (p ~ ( ~~ za. M. zs. ' lAl ws Al CAF MCCl~101', Skl, NO yay 17. PART I: Enbrtha dlseaps, inlwias orcomppcalgna wnkh 4usW lW pain DO rotemerlha modeol such as M dY1^9~ cardiac or respnalo arrest h k 1 ry , s oc or WaA L141 only oM cause On eaUl line. 8ilure I ApprO+imala PART 11: gher s~9ndkanl conpiona cunlriDUtiny ro paM. Du1 'n ~a^d rolrewamq mtM Undarryag GUp 9Np nPMTI. IMMEDIATE CAUSE IF,nal ~ cOMapn ; esWlugn deaml-~ a ~11D NYA y1Y ,4 YI"T EYIY Ot______ LO ~~ ~ -- DUE TOIOR ASACONSEOUENCE OF)' ___.__.__ seRwnmuy ks corlOilpna D. 1 ' many, Neding b unmedwu DUE TO IDR A$ A CONSEQUENCE OF): Emer UNDERLYING 1 --- - CAUSE IDiseaae q,nryry o ~ • mat gnawed evama OUE TOIOR AS A CONS[QUENCE OFI. -~. ewauy] n aealnl LAST e I WITS AN AUIOPSV WERE AUTOPSY FINDINGS MANNER OF DEATN GATE OF INJURY TIME OF INJURY IWURVd WORKt DESCRIBE NOVI INJURY OCCURRED PERFORMED? AVAILABLE PRIgi TO . IMmm. Day. YBaN COMPLETgN OF CAUSE L-~~ OF OEATH7 Narurel L 36 Homicip L 1 r~ ~ I ~ -1 Acclpnl LJ PerWUp lnvyrgalron I_J Y ~ ~~ F~t (~ ~j/ Vas ^ No L.J Yp ^ No IJ Swcip L~ ]a. OD. M. Could rot W plarminetl ^ PUCE OF INJURY ~ At Wms, farm, slrear, ladory, Oeke LOCATION IStreM CayROWrI, Sla1e1 DwMAng arc. ISpnclvl zM , . 2M. z9. ]os. ~. CERi1FIER lCnark only onel 'CERTIFYING PHYSICIANIPhysc~an cwldy~ng cause of ceam when unomer pnysK an has Vronpuncetl dedln an0 cwnol~4rp ne.+n l:ll To Me Wet o, m krrowlae a parD SIGNATURE ANO TITL ERTIFIER y y , oaune0 ew W the caupl ae staled ~ al and manner , a/D 'PRONOUNCING ANO CERTIFYING PHYSICIAN IPnysc,an tx%n ~ mnowtut~ ~ Jneam and ~enlryulg to cause of deaml . LN:ENSEN _ ---._--_----..__ __ DATE SIGNEDIMwim. Day. Ynarl Te lha Dpt olm knowle0 Y 9a, path occurree at Ma lime, dale, and Pleca, and due to Me cauaNal ml manner as araled.. alc. 't^n'"VV7V fN' __ ald. _ _ ___ _ NAME AND ADDRESS OF PERSON WHO COMPLETED CAUSE OF DEAfH - _ 'MEDICAL EXAMINER/CORONER 11 (em 27) Typs or POnI On,ne beau of a+sminatlon and/or Invesllyalion, In my opinion, dealD occurred at the Ilma, date, and place, and due to the eatlae(q and manner as atatad ........................ +e ~`-~ d3T ao~ ~ ,rJrOS"i~r •-•~ .............................................. ..... .. ...................... ]ta REGIST R SIGNATURE AND NUMBER ) / / / ~~ I IIY-11 ~O~- ]] ~2Q-c'mc3~u.st_ ~ck~ln/~~_o '~ DATE FI D (MOnM. Day. Mean a~. L'9]hC~.P X25. c~/9A.~- I ~ t/ ST W/LL AND TESTAMENT I - o a-- i oq ~- I, JEAN G. JORDAN, of 102 November Drive, Apartment No. 2, Camp Hill, Cumberland County, Pennsylvania 17011, do hereby make, publish and declare this to be my last will and testament, hereby revoking all wills heretofore made by me. 1. I direct my personal representative to pay all of my debts, funeral and administrative expenses as soon as convenient after my decease. 2. I authorize and empower my personal representative to sell any realty and/or personalty owned by me at my death and not specifically devised or bequeathed herein, at public or private sale or sales and to give good and sufficient deeds and/or bills of sale therefor, in fee simple, as I could do if living. My representative is authorized and empowered to engage in any business in which I may be engaged at my death, for such period of time after my death as seems expedient to said representative. 3. I give, devise and bequeath all of my estate of whatever nature and wherever situate as follows: A. My London Blue Topaz ring to my granddaughter, Amanda L. Jordan; and all the rest, residue and remainder of my estate as follows: B. 60% to my son, John S. Jordan, or if he is deceased, then to his children, share and share alike, the child or children of any deceased child taking the share their parent would have taken if living; and C. 40% to my son, Edward H. Jordan, or if he is deceased, then to his children, share and share alike, the child or children of any deceased child taking the share their parent would have taken if living. 4. I nominate and appoint John S. Jordan to be the personal representative of my estate, to serve without bond. If he cannot or does not serve, then I appoint Edward H. Jordan to be the substitute personal representative, also without bond. 5. I suggest that my personal representative retain the services of Harold S. Irwin, III, Carlisle, Pennsylvania in the settlement of my estate. IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~ day of December, 1997. . :.~Y1J ~ ~r'i~-~ (SEAL) JE N G. JORDAN' Signed, sealed, published and declared by the above-named person as and for a last will and testament, in our presence, who at said person's request, in said person's presence and in the presence of each other have hereunto set our names as subscribing witnesses. l~J F/, WE, JEAN G. JORDAN, HEATHER A. BARBOUR and GAY L. IRWIN, the testatrix and witnesses respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the testatrix signed and executed the instrument as her last will and that she had signed willingly, and that she executed it as his free and voluntary act for the purpose herein expressed, and that each of the witnesses, in the presence and hearing of the testator, signed the will as a witness and that to the best of their knowledge the testatrix was, at that time, eighteen years of age or older, of sound mind and under no constraint or undue influence. ~' , ~ ~, ~; JEAN' .JORDAN ~i~, HEATHER A. BAR OUR GAY L. !#~WIN COMMONWEALTH OF PENNSYLVANIA . :ss: COUNTY OF CUMBERLAND Subscribed, sworn to and acknowledged before me by JEAN G. JORDAN, the testatrix herein, and subscribed and sworn to before me by HEATHER A. BARBOUR and GAY L. IRWIN, witnesses, this ~ ~ - day of December, 1997. ~ _ Notary Public CERTIFICATION OF NOTICE UNDER RULE 5 6(al Name of Decedent: Jean G. Jordan Date of Death: November 23 2002 Will No. O~ ~ { O 9 ? Admin. No. To the Register: I certify that notice of estate administration required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following on ~ 'I ~ -~, at the below listed addresses: Name Address John S. Jordan 1808 Signal Hill Drive Mechanicsbure PA 17050 Thomas, Thomas & Hafer, LLP Edward H. Jordan Jr. P.O. Box 999 Harrisbur PA 17108 c/o Edward H. Jordan, Jr. Thomas, Thomas & Hafer, LLP Amanda L. Jordan P.O. Box 999 Harrisbur PA 17108 Notice has now been give to all persons entitled thereto under Rule 5.6(a) except: n/a Date: ~:~-'l(~ -~~ 21 '~ .~ ,~' ~~ ~~ Sign ure _Steven J. Sdhif an Esq Name 2080 Linglestown Rd., #201 Harrisburg PA 17110 Address (717) 540-9170 Telephone No. Capacity: -Personal Representative X Counsel for Personal Rep. 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 NO. CD 002156 SCHIFFMAN STEVEN J ESQUIRE 2080 LINGLESTOWN ROAD SUITE 201 HARRISBURG, PA 1 71 1 0-9483 ---- fold ESTATE INFORMATION: sSN: i46-18-x758 FILE NUMBER: 2102-1097 DECEDENT NAME: JORDAN JEAN G DATE OF PAYMENT: 02/ 1 1 /2003 POSTMARK DATE: 02/10/2003 COUNTY: CUMBERLAND DATE OF DEATH: 1 1 /23/2002 ACN ASSESSMENT AMOUNT CONTROL NUMBER 101 ~ 5915.00 TOTAL AMOUNT PAID: REMARKS: STEVEN C SCHIFFMAN ESQUIRE CHECK#1036 SEAL INITIALS: AC RECEIVED BY: DONNA M. OTTO REV-1162 EXI11-961 5915.00 DEPUTY REGISTER OF WILLS REGISTER OF WILLS a Estate Recoveries Inc. ~`" "'""" Over 15 Yenrs of Service to the Financial Industry February 27, 2003 Register Of Wills Cumberland County Courthouse 1 Courthouse Square Carlisle, PA 17013-3387 RE: Estate Of Jean G Jordan, dece~~sed. Our File#: J'~1W-40963 Estate #: 21021097 Dear Sir/Madam: Enclosed please find our claim regarding the above captioned estate which is being filed on behalf of Household Retail Services, USA, creditor. A copy of this claim is being forwarded to John Jordan, Representative for the estate. If you have any questions concerning the attached claim, please do not hesitate to contact this office. Sincerely, .Shannon K. Heim, Ext. 121 SKH Enclosure See Reverse Side For Special State Disclosures. This communication is from a debt collector. This is an attempt to collect a debt and any information obtained will be used for that purpose. P.O. Box 24566, Baltimore, Maryland 21214 5543 Hayford Road, Baltimore, Maryland 21214 Monday -Friday 8:00 am - 6:00 pm Eastern Time Telephone: 410-444-8022 R(1~-779-Ra~~ ~..... ~,,, ~„ ~,.~, STATE OF PENNSYLVANIA IN THE MATTER OF IN THE ORPHAN'S COURT ESTATE OF: OF CUMBERLAND COUNTY JEAN G JORDAN ESTATE#: 21021097 DATE OF DEATH: 11/23/2002 STATEMENT OF CLAIM 1. The creditor, Household Retail Services, USA, certifies that there is due and owing by JEAN G JORDAN, deceased, the sum of ONE THOUSAND FIFTY FIVE DOLLARS AND THIRTY ONE CENTS ($ 1,055.31). 2. The nature of the claim is a QVC account 0000061390220459. 3. The name and address of the claimant is: Household Retail Services, USA, Post Office Box 15522, Wilmington, Delaware 19850-5522. 4. The name and address of the claimant's agent is: Shannon K. Heim, Estate Recoveries, Inc., P. O. Box 24566, Baltimore, Maryland 21214. 5. This claim is not contingent and is not secured by any liens or judgments. 6. This claim is not based on any one instrument. Said balance has accrued since the account was established. On behalf of Household Retail Services, USA, creditor, I do solemnly declare and affirm under the penalties of perjury that the information in the foregoing claim is true and correct to the best of my knowledge, information and belief. I have made diligent inquiry and examination, and I believe the claim is just and all legal offsets, payments, and credits made known to the affiant have been allowed. 1~.~1~~ ~ 1~, -~ SHANNON K. HEIM Estate Recoveries, Inc. P.O. Box 24566 Baltimore, Maryland 21214 (410) 444-8022 County of Baltimore, Maryland: IN WITNESS WHEREOF, I hereunto set my hand and Notarial Seal this ebruary 27, 2003. L ~`SP M;., GfR~F LISA M. GE ,Notary Public My Commission Expires Sei~~R,).2(~04. -e-- E co~~ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION i i i File No. 21 X21097 Estate of ,lean (~ .Tordan ,Deceased NOTICE OF CLAIM by SNANN~IN K_ HF,1M AGFN,' FnR HnTTSF,HnT n RFTAH 4FRVTCF~, TT~A Filed Pursuant to Section 3532 (b) (2) of the Probate, Estate, and Fiduciary Code, 20 Pa. C. S. A § 3 5 3 2 (b) (2) . To the Clerk of the Orphans' Court Division: Enter the claim o SHANNON K_ HFTM A(`FNT FnR H[ITT~FHnT ll RFTAH CFRVT('F~~ iTCA (Claimant) in the amount of 51,055.'il against the above entitled estate. The Decedent, who resided at (Street Address) Camo H'll, A 17011 , Cnmh .rland County , (City) Pennsylvania, died on 1~TnvpmhPr 2~,~002 Written notice of said claim was given to ,lohn .Tordan (Personal Representative, or his Counsel) If known to claimant, at 1808 Single Hill Dr. _Mechanicsburg PA 17050 won Fehr-nary 27, 2003 ( Address) (Date) SHANNON K. HEIM, AGENT Claimant Post Office Box 24566, Baltimore, Maryland 21214 ( Address) Claimant's Counsel: ( Address) Pa3e: 1 Document Name: untitled (/ ARSD ( ) HRS USA WEST APWH 2.5 PAGE 03 -- --- - - --- -- - 02/07/2003 ON-LINE STATEMENT HISTORY DISPLAY 04:43:56 ORGANIZATI * ON 649 LOGO 604 ACCOUNT 0000000061390220459 -------- INFORMATI ON BELOW REFLECTS THE ACCOUNT AT STATEMENT TIME --- * BILLING CYCLE 10 DATE THIS STMT 10102002 ------ SHORT NAME JORDAN JEAN STATE OF RESID PA DATE LAST STMT 09102002 , CUST NBR 0000000061390220459 INTERNAL STATUS A CYC/DATE DUE 07 11052002 ALT CUST GRACE EXPIRE 11102002 REL NBR BLOCK CODE 1 BLOCK CODE 2 M CREDIT LIMIT .00 STORE ORG 649 ID 002664921 P OPEN TO BUY *** *******_00 OVRLIMT INCLUDED N STATEMENT FLAG O CASH LIMIT .00 CURR PMT DUE STAT CODE DM CASH AVAIL .00 TOTAL PAST DUE 103.00 547 00 BD PH LGC 02 Y-T-D INTEREST 149.28 TOTAL PMT DUE . 650 00 INS STAT Y-T-D LATE CHG 120.00 FIXED PMT AMT . 00 GUARANTOR Y-T-D OVLM CHG .00 . ST CP # SPCL CLASS 08 LAST YTD INTR 74.95 INTEREST FREE 1,021.70 INT THIS STMT 13.61 EMPLOYEE CODE F/S BEG BAL CREDIT CLASS I1 F/S EARNED 0 BEG BAL RECENCY FLAG 6 F/S ADJ 0 DEBI`T'S 2 988 Og DAYS IN CYCLE 30 F/S DISB 0 CREDITS 0 33.61 NBR OF PLANS 1 F/S END BAL 0 END BAL .00 PFI=ARMU PF2=ARTD PF3=ARIQ PF4=ARIH PF5=ARQB 1,021.70 PF6=ARQE Date: 02/07/2003 Time: 7:43:58 AM Pa3e: 1 Document Name: untitled D ) ____ --- HRS USA WEST APWH 2.5 PAGE 04 02/07/2003 ON-LINE STATEMENT HISTORY DISPLAY 04:43:59 ORGANIZAT ION 649 LOGO 604 ACCOUNT 0000000061390220459 RQ EFF POST CR DATE DATE AMOUNT TXN PLAN *-----___ D E S C R I P T I O N-- * 1010 1010 20.00 D701 ----- 8 LATE CHARGE ASSESSMENT PTS= 0 0 DEPT = REF=10026649210000001476950 AUTH= SEQ=01 STORE=002664921 SKU=000000000 GLS=1 SALESCLERK=P01 TKT= ORG=000 P/0= MERCH=000000000 R/REF=00000000000000 ITM=76950 CAT=0000 CARD#/SEQ#=0000000061390220459 1010 1010 13.61 D714 0000 8 BILLED FINANCE CHARGES PTS= 0 0 DEPT = REF=10026649210000001476960 AUTH= SEQ=01 STORE=002664921 SKU=000000000 GLS=1 SALESCLERK=P01 TKT= P/0= R/REF=00000000000000 ITM=76960 ORG=000 MERCH=000000000 CAT=0000 CARD#/SEQ#=00000000 61390220459 0000 *** END OF TRANSACTIONS *** PFI=ARMU PF2=ARTD PF3=*TOP* PF4=*BOT* PF5=*BWD* PF6=*FWD* Date: 02/07/2003 Time: 7:44:00 AM Pa3e: 1 Document Name: untitled ARSD ( ) HRS USA WEST APWH 2.5 PAGE 03 02/07/2003 ON-LINE STATEMENT HISTORY DISPLAY 04:44:04 ORGANIZATION * 649 LOGO 604 ACCOUNT 0000000061390220459 -------- INFORMATION BELOW REFLECTS THE ACCOUNT AT STATEMENT TIME --- * BILLING CYCLE 10 DATE THIS STMT 11102002 ------ SHORT NAME JORDAN JEAN STATE OF RESID PA DATE LAST STMT 10102002 , CUST NBR 0000000061390220459 INTERNAL STATUS A CYC/DATE DUE 08 12062002 ALT OUST GRACE EXPIRE 12102002 REL NBR BLOCK CODE 1 BLOCK CODE 2 M CREDIT LIMIT .00 STORE ORG 649 ID 002664921 P OPEN TO BUY **********.00 OVRLIMT INCLUDED N STATEMENT FLAG O CASH LIMIT .00 CURR PMT DUE STAT CODE DM CASH AVAIL .00 TOTAL PAST DUE 106.00 BD PH LGC 02 Y-T-D INTEREST 162.89 TOTAL PMT DUE 650.00 INS STAT Y-T-D LATE CHG 140.00 FIXED PMT AMT 756.00 GUARANTOR Y-T-D OVLM CHG .00 .00 ST CP # SPCL CLASS 08 LAST YTD INTR 74.95 INTEREST FREE 1,055.31 INT THIS STMT 13.61 EMPLOYEE CODE F/S BEG BAL CREDIT CLASS I1 F/S EARNED 0 BEG BAL RECENCY FLAG 7 F/S ADJ 0 ' 1,021.70 DAYS IN CYCLE 31 F/S DISB 0 llEBI .PS 2 33.61 NBR OF PLANS 1 F/S END BAL 0 CREDITS 0 .00 PFI=ARMU PF2=ARTD PF3=ARIQ PF4=ARIH END BAL PF5 AR 1,055.31 = QB PF6=ARQE Date: 02/07/2003 Time: 7:44:06 AM Pale: 1 Document Name: untitled ARSD ( ) HRS USA WEST APWH 2.5 PAGE 04 02/07/2003 ON-LINE STATEMENT HISTORY DISPLAY 04:44:07 ORGANIZAT ION 649 LOGO 604 ACCOUNT 0000000061390220459 RQ EFF POST CR DATE DATE AMOUNT TXN PLAN *-------- D E S C R I P T I O N- * 1110 1110 20.00 D701 ------ 8 LATE CHARGE ASSESSMENT PTS= 0 0 DEPT= REF=10026649210000001467470 AUTH= SEQ=01 STORE=002664921 SKU=000000000 GLS=1 SALESCLERK=P01 TKT= P/0= R/REF=00000000000000 ITM=67470 ORG=000 MERCH=000000000 CAT=0000 CARD#/SEQ#=0000000061390220459 1110 1110 13.61 D714 0000 8 BILLED FINANCE CHARGES PTS= 0 0 DEPT = REF=10026649210000001467480 RUTH= SEQ=01 STORE=002664921 SKU=000000000 GLS=1 SALESCLERK=P01 TKT= P/0= R/REF=00000000000000 ITM=67480 ORG=000 MERCH=000000000 CAT=0000 CARD#/SEQ#=000000006 1390220459 0000 *** END OF TRANSACTIONS *** PFI=ARMU PF2=ARTD PF3=*TOP* PF4=*BOT* PF5=*BWD* PF6=*FWD* Date: 02/07/2003 Time: 7:44:08 AM Pa.~e: 1 Document Name: untitled ARSD ( ) HRS USA WEST APWH 2.5 PAGE 03 02/07/2003 ON-LINE STATEMENT HISTORY DISPLAY 04:44:12 ORGANIZATION 649 LOGO 604 ACCOUNT 0000000061390220459 *-------- INFORMATION BELOW REFLECTS THE ACCOUNT AT STATEMENT TIME ---------* BILLING CYCLE 10 DATE THIS STMT 12102002 SHORT NAME JORDAN,JEAN STATE OF RESID PA DATE LAST STMT 11102002 OUST NBR 0000000061390220459 INTERNAL STATUS Z CYC/DATE DUE 08 01052003 ALT CUST GRACE EXPIRE 01102003 REL NBR BLOCK CODE 1 M CREDIT LIMIT .00 STORE ORG 649 ID 002664921 BLOCK CODE 2 Z OPEN TO BUY **********,00 OVRLIMT INCLUDED N STATEMENT FLAG O CASH LIMIT .00 CURR PMT DUE STAT CODE DM CASH AVAIL 106.00 .00 TOTAL PAST DUE 650.00 BD PH LGC 02 Y-T-D INTEREST 162.89 TOTAL PMT DUE INS STAT 756.00 Y-T-D LATE CHG 140.00 FIXED PMT AMT .00 GUARANTOR Y-T-D OVLM CHG .00 ST CP # 08 LAST YTD INTR 74.95 INTEREST FREE SPCL CLASS TNT THIS STMT .00 .00 EMPLOYEE CODE F/S BEG BAL CREDIT CLASS M6 F/S EARNED 0 BEG BAL 1,055.31 RECENCY FLAG 8 F/S ADJ 0 DEBI'T'S 0 DAYS IN CYCLE 20 F/S DISB .00 0 CREDITS 0 .00 NBR OF PLANS 1 F/S END BAL 0 END BAL PFI=ARMU PF2=ARTD PF3=ARIQ PF4=ARIH PF5=ARQB PF61ARQE'31 Date: 02/07/2003 Time: 7:44:13 AM Pa3e: 1 Document Name: untitled ARSD ( ) HRS USA WEST APWH 2.5 PAGE 04 02/07/2003 ON-LINE STATEMENT HISTORY DISPLAY 04:44:14 ORGANIZATION 649 LOGO 604 ACCOUNT 0000000061390220459 RQ EFF POST CR DATE DATE AMOUNT TXN PLAN *-------- D E S C R I P T I O N-------* 1130 1130 1,055.31 C718 0 AUTOMATIC INITIAL CHARGEOFF PTS= 0 0 DEPT= REF=10026649210000000027060 AUTH= STORE=000000000 SKU=000000000 GLS=1 SALESCLERK=P02 TKT= P/0= R/REF=00000000000000 ITM=27060 ORG=000 MERCH=000000000 CAT=0000 CARD#/SEQ#=0000000061390220459 0000 *** END OF TRANSACTIONS *** PFI=ARMU PF2=ARTD PF3=*TOP* PF4=*BOT* PF5=*BWD* PF6=*FWD* Date: 02/07/2003 Time: 7:44:15 AM P~.3e: 1 Document Name: untitled ARSD ( ) HRS USA WEST APWH 2.5 PAGE 03 02/07/2003 ON-LINE STATEMENT HISTORY DISPLAY 04:44:18 ORGANIZATI * ON 649 LOGO 604 ACCOUNT 000000006139022 0459 -------- INFORMATION BELOW REFLECTS THE ACCOUNT AT STATEMENT TIME -- * BILLING CYCLE S 10 DATE THIS STMT 01102003 ------_ SHORT NAME JORDAN JEAN TATE OF RESID INTERNAL STATUS PA Z DATE LAST STMT CYC/DATE 12102002 , OUST NBR 0000000061390220459 DUE 08 02052003 ALT CUST GRACE EXPIRE 02102003 REL NBR BLOCK CODE 1 BLOCK CODE 2 K CREDIT LIMIT .00 STORE ORG 649 ID 002664921 Z OPEN TO BUY **********.00 OVRLIMT INCLUDED N STATEMENT FLAG O CASH LIMIT .00 CURR PMT DUE STAT CODE ER CASH AVAIL .00 TOTAL PAST DUE 106.00 BD PH LGC 02 Y-T-D INTEREST 162.89 TOTAL PMT DUE 650.00 INS STAT Y-T-D LATE CHG .00 FIXED PMT AMT 756.00 GUARANTOR Y-T-D OVLM CHG .00 .00 ST CP # OS LAST YTD INTR .00 INTEREST FREE SPCL CLASS INT THIS STMT .00 .00 EMPLOYEE CODE F/S BEG BAL CREDIT CLASS M6 F/S EARNED 0 BEG BAL RECENCY FLAG 9 F/S ADJ 0 ' 1,055.31 DAYS IN CYCLE 0 F/S DISB 0 DEBI ~S 0 .00 NBR OF PLANS 1 F/S END BAL CREDITS 0 .00 PFI=ARMU PF2=ARTD PF3=ARIQ 0 PF4=ARIH END BAL PF5=AR B 1,055.31 Q PF6=ARQE Date: 02/07/2003 Time: 7:44:20 AM /2 ~°~- ~ BUREAU OF INDIVIDUAL TAXES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX DIVISION DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-D6o1 NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX REV-1547 E% AFP (31-037 ~`'~ r`- BATE 05-19-2003 ~~ ~ _ `' ESTATE OF JORDAN JEAN G DATE OF DEATH 11-23-2002 ~~3 I°iAY 23 ~(iv ;E~jLE NUMBER 21 02-1097 STEVEN J SCHIFFMAN ESQ ~OUNTY CUMBERLAND SERRATELLI ETAL ACN 101 2080 LINGLESTOWN RD t-+~`~~` - Amount Remitted HBG PA 17110~st 17t1~- ' . -. MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE - RETA_IN LOWER POR_TION_ FOR YOUR RECORDS ~ ----------------------------------------- REV-1547 EX AFP (O1-03) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR --------------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF JORDAN JEAN G FILE N0. 21 02-1097 ACN 101 DATE 05-19-2003 TAX RETURN WAS: ()C) ACCEPTED AS FILED ( l 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 2. Stocks and Bonds (Schedule B) proper (2) .00 credit to your account, 3. Closely Held Stock/Partnership Interest (Schedule C) (3) .00 submit the upper portion 4. Mortgages/Notes Receivable (Schedule D) (4) .00 of this fore with 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) 8,197.00 tax Your payment. 6. Jointly Owned Property (Schedule F) (6) .00 7. Transfers (Schedule G) (7) 21,401.00 8. Totai Assets (g) 29,598.00 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9) 4,993.0 0 10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) 6,219 00 11. Total Deductions (11) -_ 11 1 00 12. Net Value of Tax Return (12) 18,387.00 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) (13) .00 14. Net Value of Estate Subject to Tax (14) 18,387.00 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 (15) • 00 X 00 _ . 00 16. Amount of Line 14 taxable at Lineal/Class A rate (16) 21,401.00 X 045 = 963.00 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)= 963.00 TAX CREDITS: DATE -10-2 2 /PEN PAID (-) I AMOUNT PAID TOTAL TAX CREDIT 963.15 BALANCE OF TAX DUE .15CR INTEREST AND PEN. .00 TOTAL DUE .15CR * IF PAID AFTER DATE INDICATED, SEE REVERSE ( IF TOTAL DUE IS LESS THAN S1, NO PAYMENT IS REQUIRED. FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE STnF nr TuTe rnsu ~.... _..___..______- IN RE: Estate of Jean G. Jordan, Deceased IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION No. 2002-01097 FIRST AND FINAL ACCOUNTING OF JOHN S. JORDAN EXECUTOR OF THE ESTATE OF JEAN G. JORDAN Date of Death: Date of Appointment: Dates of Advertisement: 1. Cumberland Law Journal: 2. The Sentinel November 23, 2002 December 5, 2002 December 20, 27, 2002, January 3, 2003 December 13, 20 & 27, 2002 Steven J. Schiffinan, Esq. SERRATELLI, SCHIFFMAN, BROWN & CALHOON, P.C. 2080 Linglestown Road, Suite 201 Harrisburg, PA 17110 (717) 540-9170 Supreme Court LD. #25488 Estate of Jean G. Jordan Receipts of Principal Cash and Cash Equivalents Commonwealth of Pennsylvania PNC Bank Checking Account #50-0081-3338 Total Cash and Cash Equivalents Tangible Personal Property Personal Property Total Tangible Personal Property Total INVENTORY RECEIPTS SUBSEQUENT TO INVENTORY 12/23/2002 Pennsylvania Department of Revenue 01/06/2003 Outlook Pointe at Creekview 01/16/2003 Senior Blue Total RECEIPTS SUBSEQUENT TO INVENTORY ADJUSTMENTS TO CARRYING VALUE 11/23/2002 Personal Property Adjusted value upon audit valued at VALUE PER INVENTORY VALUED AT Total ADJUSTMENTS TO CARRYING VALUE Inventory Value 11/23/2002 $ 21.00 6,826.86 $ 6,847.86 Inventory Value 11 /23/2002 $ 100.00 100.00 $ 6,947.86 $ 89.00 1,127.40 54.00 1,270.40 $ (100.00) 0.00 (100.00> Page 1 (2) Receipts of Principal (Continued) Total Receipts of Principal $ 8,118.26 Page 2 ~3~ Estate of Jean G. Jordan Gains and Losses on Sales or Other Dispositions of Principal Net Gain Net Loss 12/16/2002 Collection PNC Bank Checking Account #50-0081-3338 Net Proceeds $ 6,826.86 Carried at 6,826.86 12/23/2002 Collection Pennsylvania Department of Revenue Net Proceeds $ 89.00 Carried at 89.00 01/06/2003 Collection Outlook Pointe at Creekview Net Proceeds $ 1,127.40 Carried at 1,127.40 01/16/2003 Collection Senior Blue Net Proceeds $ 54.00 Carried at 54.00 01/16/2003 Collection UNKNOWN DEPOSIT Net Proceeds $ 21.00 Carried at 21.00 Total Gains and Losses No Gain or Loss o.oo $ $ o.oo o.oo Page 1 ~4) Estate of Jean G. Jordan Disbursements of Principal Date Paid Amount Paid Claims presented, allowed, paid, credited and appearing in the Summary Statement Claremont Nursing and Rehab Center 01 /06/2003 $ 1, 7 5 2.2 2 Total Claremont Nursing and Rehab Center $ 1 752.22 Total Claims presented, allowed, paid, $ 1,752.22 credited and appearing in the Summary Statement Funeral Expenses Laurel Memorial Park Pomona, NJ 01 /06/2003 $ 4 7 5.0 0 Total Laurel Memorial Park Pomona, NJ $ 475.00 Neill Funeral Home, Inc. 01 /06/2003 $ 2 , 3 21.0 0 Total Neill Funeral Home, Inc. ~ 2 321.00 Total Funeral Expenses $ 2,7ss.oo Administration Expenses John S. Jordan 01/06/2003 (Reimbursement of Costs $ 142.94 re: Mileage - Interment) Total John S. Jordan $ 142.94 Page 1 ~5) Disbursements of Principal (Continued) Date Paid Amount Paid Administration Expenses Monument 01 /06/2003 $ 2 s 9. o 0 Total Monument ~ 2ss.oo PNC Bank 12/24/2002 (Estate Check Charges) $ 27.60 Total PNC Bank Total Administration Expenses Total Disbursements of Principal ~ 27.so $ 459.54 5,007.76 Page 2 ~g~ Estate of Jean G. Jordan Distributions of Principal to Beneficiaries Distribution Value Total Distributions of Principal 0.00 Page 1 ~7~ Estate of Jean G. Jordan Principal Balance On Hand Valued as of October 14, 2003 Cash and Cash Equivalents PNC Bank Estate Account Total Cash and Cash Equivalents Total Balance on Hand Inventory Value $ 3,110.50 3,110.50 $ 3,110.50 Page 1 ~g~ Estate of Jean G. Jordan Information Schedules - Principal Exchanges and Stock Distributions London Blue Topaz Ring 11/23/2002 Outlook Pointe at Creekview 01/06/2003 01/06/2003 Pennsylvania Department of Revenue 12/23/2002 12/23/2002 Personal Property 11/23/2002 11/23/2002 Received $ The decedent's will provided for the specific devise of this ring to her granddaughter; however, the ring did not exist at the time of death. Received (Refund) Collected Received (2001 Pennsylvania Personal Income Tax Refund) Collected Received The Decedent was residing in a nursing home at the time of her death and had limited personal property. The cost of an appraisal was not warranted. Adjusted (The personal property was valued at $100.00 for tax purposes; however, the property was GIVEN TO CHARITY/DISPOSED OF and no funds were received for the property) Inventory Value 0.00 $ 1,127.40 (1,127.40) $ 89.00 (89.00) $ 100.00 (100.00) Page 1 (g) Information Schedules -Principal (Continued) Exchanges and Stock Distributions Senior Blue 01/16/2003 Received (Refund of Medical Insurance) 01/16/2003 Collected Inventory Value $ 54.00 (54.00) Page 2 (10) Estate of Jean G. Jordan Unpaid Principal Expenses Debts of Decedent Bank One $ 4,837.21 Total Bank One $ 4,837.21 Borrebach Tomlinson Re: The Swiss Colony - $165.14 Ginny's - $212.92 $ 378.06 Total Borrebach Tomlinson $ 378.06 Boscov's $ 465.48 Total Boscov's $ 465.48 Citifinancial $ 2,824.77 Total Citifinancial Commonwealth of Pennsylvania Property Tax/Rent Rebate Division (Rent Rebate which Deceased received but was not entitled according to a revision of her 2002 Personal Income Tax Return) Total Commonwealth of Pennsylvania Property Tax/Rent Rebate Division $ 2,824.77 $ 156.00 $ 156.00 Page 1 (11) Unpaid Principal Expenses (Continued) Debts of Decedent CRA Re: Blair Credit Services Total CRA Re: Blair Credit Services Household Retail Services, USA Account#0000061390220459) (c/o Estate Recoveries, Inc.) 747.95 Total Household Retail Services, USA Account#0000061390220459) (c/o Estate Recoveries, Inc.) Verizon Total Verizon Total Debts of Decedent Administration Expenses Cumberland Law Journal $ 747.95 $ 1,055.31 $ 1,055.31 $ 120.90 ~ 120.90 $ 10.585.68 $ 75.00 Total Cumberland Law Journal John S. Jordan (Executor Commission) Total John S. Jordan $ 75.00 $ 500.00 $ 500.00 Page 2 (12) Unpaid Principal Expenses (Continued) Administration Expenses Register of Wills Total Register of Wills Serratelli, Schiffman, Brown & Calhoon, P.C. Total Serratelli, Schiffman, Brown &Calhoon, P.C. The Sentinel Total The Sentinel Total Administration Expenses $ 91.00 $ 91.00 $ 1,000.00 $ 1,000.00 $ 71.33 $ 71.33 $ 1.737.33 Total Unpaid Expenses $ 12,323.01 Page 3 (13) Estate of Jean G. Jordan Principal Unrealized Gains and Losses Total Unrealized Market Value Inventory Value Gain or (Loss) $ 0.00 $ 0.00 $ 0.00 Page 1 (14) Estate of Jean G. Jordan Receipts of Income Total Income Received $ o.oo Page 1 (15) Estate of Jean G. Jordan Gains and Losses on Sales or Other Dispositions of Income Net Gain Net Loss No Gain or Loss $ o.oo Page 1 (16) Date Paid Estate of Jean G. Jordan Disbursements of Income Total Disbursements of Income Amount Paid ~ 0.00 Page 1 (17) Estate of Jean G. Jordan Distributions of Income to Beneficiaries Distribution Value Total Distributions of Income 0.00 Page 1 ~1 g) Estate of Jean G. Jordan Income Balance On Hand Valued as of October 14, 2003 Inventory Value Total Balance on Hand $ o.oo Page 1 (19) Estate of Jean G. Jordan Income Unrealized Gains and Losses Market Value Inventory Value Gain or (Loss) Page 1 (20~ RULE 6.3-1 CERTIFICATION I, Steven J. Schiffman, Esquire, do hereby certify that the requirements of Rule 6.3-1 regarding notice have been met in the matter of the Estate of Jean G. Jordan. Dated: 1 s ~ ~ v . S iffm squire PROPOSED SCHEDULE OF DISTRIBUTION Balance on Hand Available for Distribution: $3110.50 (1) Class 1 Unpaid Creditors (Costs of Administration) a. Register of Wills (Estimate Accounting Fees) 170.00 b. Executor Commission 500.00 c. Cumberland Law Journal 75.00 (Estate Ad) (Advanced Cost) d. Register of Wills (Probate Fee) 91.00 (Advanced Cost) e. The Sentinel (Estate Ad) 71.33 (Advanced Cost) f. Serratelli, Schiffinan, Brown & Calhoon 1000.00 (2) Class 2 Unpaid Creditor (Family Exemption) N/A (3) Class 3 Unpaid Creditors (Costs of the decedent's PAID funeral and burial; costs of medicines furnished to him/her within six months of his death; costs of medical and nursing services performed for him/her within that time and costs of services performed for him/her by any of his employees within that time.) (4) Class 4 Unpaid Creditors (Cost of a gravemarker) PAID (5) Class 5 Unpaid Creditors (Rents for occupancy of the N/A decedent's residence for six months immediately prior to his/her death.) Balance: 1203.17 (6) Class 6 Unpaid Creditors (All other claims, including claims of the Commonwealth) (a) Bank One 4837 10,585 X 1203.17 = 549.81 (b) Borrebach Tomlinson 378 10,585 X 1203.17 = 42.97 (c) Boscov's 465 10,585 X 1203.17 = 52.86 (d) Citifinancial 2825 10,585 X 1203.17 = 321.11 (e) Commonwealth of Pennsylvania Property Tax/Rent Rebate Division 156 10,585 X 1203.17 = 17.73 (f) CRA Blair Credit Services 748 10,585 X 1203.17 = 85.02 (g) Household Retail Services 1055 10,585 X 1203.17 = 119.92 (h) Verizon 121 10,585 X 1203.17 = 13.75 BALANCE: -0- John S. Jordan, Executor, hereby declares under oath (penalties of perjury) that he has fully and faithfully discharged the duties of his office; that the foregoing First and Final Accounting is true and correct and fully discloses all significant transactions occurring during the accounting period; that all known claims against the estate have been paid in full except as disclosed herein; that, to his knowledge, there are no claims now outstanding against the Estate which have not been disclosed herein; and that all taxes presently due from the Estate have been paid. ~"' '~ ~; JO S. JO AN COMMONWEALTH OF PENNSYLVANIA: SS COUNTY OF ~~~ (-~ : On this, theme day of ~~~~" , 2003, before me, a Notary Public, the undersigned officer, personally appeared John S. Jordan, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument and acknowledged that he executed the same for the purposes therein contained. Title of Officer My Commission Expires: -~~ set Gwen M. Cledc, Notary Public City Of Ftamsburg, Courtly My Conmission Expires Oct. 27, 2006 Member, Pennsylvania Assodatlon Of Notaries IN RE: Estate of Jean G. Jordan, : IN THE COURT OF COMMON PLEAS Deceased :CUMBERLAND COUNTY, PA No. 2002-01097 Orphans' Court Division AFFIDAVIT OF SERVICE I, Steven J. Schiffinan, being duly sworn according to law, depose and say that the First and Final Account and Proposed Schedule of Distribution of John S. Jordan, Executor of the Estate of Jean G. Jordan, filed in the above captioned matter, was served upon the following creditors and interested parties by United States mail, certified, postage prepaid, addressed as follows: CBCS Estate Recoveries, Inc. P.O. Box 69 P.O. Box 24566 Columbus, OH 43216 Baltimore, MD 21214 CRA 4505 North Front Street P.O. Box 67555 Harrisburg, PA 17106-7555 CitiFinancial Investment Recovery 11436 Cronhill Drive, Suite H Owings Mills, MD 21117 Borrebach Tomlinson Suite 205 20 South Olive Street Media, PA 19063 Anita Bullock Property Tax/Rent Rebate Div. Department of Revenue Bureau of Individual Taxes Dept. 280602 Harrisburg, PA 17128-0602 Boscov's #75111 P.O. Box 741026 Dallas, TX 75374 Bank One Estates Department P.O. Box 8650 Wilmington, DE 19899-8650 Edward H. Jordan, Jr. THOMAS, THOMAS & HAFER, LLP P.O. Box 999 Harrisburg, PA 17108 (See Attached Return Receipt Cards) Steven J. Schif an, sq. SERRATELL , SCH FMAN, BROWN & CALHOO , P.C. 2080 Linglestown Rd., Suite 201 Harrisburg, PA 17110 (717) 540-9170 Sworn and Subscribed to befor me this ~ Y~day of ./, 2003. ~. NOTARY PUB IC Affidavi.Ser NOTARIAL SEAL DEBRA A. EVANGELISTI, Notary Public Susquehanna Twp., Dauphin County ; M Commission Expires May 7, 200 ^ Complete items 1, 2, and 3. Also complete item 4 'rf Restricted Delivery is desired. ^ Print your name and address on the reverse so that we can return the card to you. ^ Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: CBCS P.O. Box 69 Columbus, OH 43216 A. Sf re ^ Agent ^ Addressee wed Name) C. Date of Delivery D. Is delivery address different from kem 1? ^ Yes ff YES, enter delivery address below: ^ No DEC 1 6 2003 3. Service Type ~7 Certified Mail ^ Express Mail ^ Registered >CI Retum Receipt for Merchandise ^ Insured Mail ^ C.O.D. 4. Restricted Delivery? (Extra Fee) ^ Ygs 2. Article Number (lianster from service /abep 7 0 0 2 31 5 0 0 0 01 8 2 4 0 5 6 6 4 PS Form 381 ~ , August 2001 Dort~tFc Rshrn Receipt igR$s5~R-M-1540 ^ Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. ^ Print your name and address on the reverse so that we can return the card to you. ^ Attach this card to the back of the mailpiece or on the front if space permits. 1. Article Addressed to: Estate Recoveries, Inc. P.O. Box 24566 Baltimore, MD 21214 A. ^ Agent B. Received by (Pr/nted Name) I C. Date of [ iL-t l - D. Is delivery address different from item 1? ^ Yes If YES, enter delivery address below: O No 3. Service Type ~ Certified Mail ^ Express Mail ^ Registered ise ^ Insured Mail ^ C.O.D. 4. Restricted Delivery? (Extra Fee) ^ Y~ 2. Article Number (Transfer from service iat~ 7 0 0 2 31 5 0 0 0 01 8 2 4 0 5 6 4 0 PS Form 3811, August 2001 ~ : Dorrx~tijeAeturp , . ~ - ~:~;, ~: ~.... , .. ' ~: ~ e ~ 102595-02-frF-1540 ^ Complete items 1, 2, and 3. Also complete item 4 'if Restricted Delivery is desired. ^ Print your name and address on the reverse so that we can return the card to you. ^ Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: CRA 4505 North Front Street P.O. Box 67555 Harrisburg, PA 17106-7555 A. Signature xAgent ^ Addressee B. R b nn ~ ~ C. Date of Delivery D: Is delivery address ditfbrent from item if ~ ~~ If YES, enter delivery address below: ^ No 3. Service Type $l Certified Mail ^ Express Mali ^ Registered ~1 Return Receipt for Merchandise ^ Insured Mail ^ C.O.D. 4. Restricted Delivery? (Exha Fee) ^ Yes 2. Article Number frransfer bnm serofce isdan. 7 0 0 31 ~ 0 0 O n 1' 8 4 (3 ~ ti ~ 9 PS Form 3811, August 2001 Domestic Return gr~mriF+t lozsss-oz-M-lsao ^ Complete items 1, 2, and 3. Also complete item 4 'rf Restricted Delivery is desired. ^ Print your name and address on the reverse so that we can return the card to you. ^ Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: Anita Bullock Property Tax/Rent Rebate D Department of Revenue Bureau of Individual Taxes Dept. 280602 Harrisburg, PA 17128-0602 a B. Received by (Printed Name) I,O. ~at8lo~~livery ~~~Z In"- J D. Is delivery address different from item 1? ^ Yes If YES, enter delivery address below: ^ No 3. Service Type C~Certified Mail ^ Express Mall ^ Registered C~Return Receipt for Merchandise ^ Insured Mail ^ C.O.D. 4. Restricted Delivery? (Extra Fee) ^ Yes 2. Article Number (Transfer from service label) 7 0 0 2 31 5 0 0 0 01 8 2 4 0 5 6 3 3 PS Form 3811, August 2001 Domestic Return Receipt 102595-02-M-1540 ^ Complete items 1, 2, and 3. Also complete item 4 ff Restricted Delivery is desired. ^ Print your name and address on the reverse so that we can return the card to you. ^ Attach this card to the back of the mailpiece, or on the front if space Permits. 1. Article Addressed to: CitiFinancial Investment Recovery 11436 Cronhill Drive, Suite H Owings Mills, MD 21117 A SI nature 3. Service Type ^ Cert~ed Mail ^ Express Mail ^ Registered ^ Return ReCei t ^ Insured Mail ^ C.O.D. P ~ Merchandise 4. Restricted Delivery? (Extra Fee) 2. Article Number ^ Yes (Tiarrsfer horn servke label) PS Form 3811, August 2001 Do~enc Return Pt ro2sss-o2-nn-1540 ^ Complete items 1, 2, and 3. item 4 if Restricted Relive Also complete ^ Print your name and address' onestred, so that we can return the ~ roverse ^ Attach this card to the card tO y°u. or on the front ~ space back of the mailpiece, Permits. 1 • Article gddreS38d to: Boscov's #75111 P•O• Box 741026 Dallas, TX 75374 2• Article Number-~ (Transfer /yre s~,~ label) PS Form 3811, ,august 2001 a ^ Agent /'~JV ,/V` C• Date of Delivery D. Is delivery address/ dfff :__,„ If YES, eater delive Brent front ~~ 17 ^ Yes ^~~ low: ^ No i ,~ 3• Service Type Cerfrfled Mail ^ ^ Registered ExP-ess Mail ^ Insured ~ Return Receipt for Merchandise Mail ^ C.O.D. 4• Restricted Delivery? (Extra ~) N ~GG~ ^ Agent B. R 'ved by (Prlnred Name ^ Addresses C. Date of Delivery D. Is delivery address d~~rn Ttorn item 17 Yes, If YES, enter delivery address below: ^ No ^ Yes 102595-02_M_~sgp ^ Complete items 1, 2, and 3. Also complete item 4 ff Restricted Delivery is desired. ^ Print your name and address on the reverse so that we can return the card to you. ^ Attach this card to the back of the mailpiece, or on the front ff space permits. 1. Article Addressed to: Borrebach Tomlinson Suite 205 20 South Olive Street Media, PA 19063 A Slgnat X - /Jj ~/ ~ 1~ Agent ~'-v ~/~ ^ Adpd~ressee B. Rec ved by ~~ app) ~ ~n,~r /_ 13 ry . Is delivery address dfffenent from item 1? (^ Ye/sv If YES, enter delivery address below: ^ No 3. Service Type ~} Certified Mail ^ Express Mail ^ Registered f{7 Retum Receipt for Merchandise ^ Insured Mail ^ C.O.D. 4. Restricted Delivery? (Extra Fee) ^ Yes 2. Article Number (transfer from servioelatteq 7 ,0 2 31 Si? ©O Q 1 $2 ~ 0 5 6 2 ~' PS Form 3811, August 2001 Dorneatfc Retum 102595.02-M-1540 ^ Complete items 1, 2, and 3. Also complete item 4 if ResMcted Delivery is desired. ^ Print your name and address on the reverse so that we can return the card to you. ^ Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: Bank One Estates Department P.O. Box 8650 Wilmington, DE 19899-8650 A. Signature x ^ Agent ^ Addressee B. Fjeceived by (PrintedNa m e) / C. Date of Delivery 'f ~` L . 4 .: D. Is delivery address d iffero M itENrhl ti? ~ If YES, enter delivery ad oW; ' ~~~ z P L `•`°od 3. Service Type ' ,p~ ~7 Certified Mail ^ Express Mai J ^ Registered ~ Retum Receipt for Merchandise ^ Insured Mail ^ C.O.D. 4. Restricted Deliveryi (Extra Fee) ^ Yes 2. Article Number (Tiansferfromservice~ '700 3150 0001 8240 5602 PS Form 3811, August 2001 DorrraeUc gaEurn 102595-02-M-1540 ^ Complete items 1, 2, and 3. Also complete ftem 4 if Restricted Delivery is desired. ^ Print your name and address on the reverse so that we can return the card to you. ^ Attach this card to the back of the mailpiece, or on the front if space permits, 1. Article Addressed to: Edward H. Jordan, Jr. THOMAS, THOMAS & HAFER, LL P.O. Box 999 Harrisburg, PA 17108 2. Article Number A Signatix~e _ ^ Addre B. Received by (Printed Name) C. Date of Deli D. Is delivery address different horn item 1? ^ Yes If YES, enter delivery address below: ^ No 3. Service Type ~1 Certified Mail ^ Express Mail ^ Registered ~! Retum Receipt for Merchandise ^ Insured Mail ^ C.O.D. 4. Restricted Delivery? (~-a Fee) ^ Yes FtugUSi LOUI DOrflt' ' ~ I~~ ~ 102595-02-M-1540 1` ~~~ _Estat_e_ Reco verses, Inc.. ''~ a~~,» Oren 1 ? }'rni~c r,j.S<~rrlre n~ iht~ /~inancial li~el«s~i ~~ February 5, 2004 REGISTER OF WILLS CUMBERLAND COUNTY COURTHOUSE 1 COURTHOUSE SQUARE CARLISLE, PA 17013-3387 Our File #: JHW-40963 Dear Sir/Madam: Enclosed please find a release to be filed in the estate as referenced. If there are any questions concerning the enclosed document, please feel free to contact our office. Thank you for your cooperation in this matter. sincerely, _ ~~ Financial ~ e ment 410-444-8022 Ext. 294 ~_ ~` _ Encl. - `-' ° ~^~ Sys:relcvr ,.~, i -~ ti~ w See Reverse Side For Special State Disclosures. This communication is from a debt collector. This is an attempt to collect a debt and any information obtained will be used for that purpose. P.O. Box 24566, Baltimore, Maryland 21214 5543 Hanford Road, Baltimore, Maryland 21214 Mnnr)av - Frir~ac R•(~(1 am , Fi•Il[l ,,,,, F~~ro~., T:..~.,. _ T~1__L._-. n i n e ~ n nn~-~ ,,,.,. ,...,. ., .-- IN RE: ESTATE OF: JEAN G. JORDAN ESTATE NO. 21021097 DECEASED. SATISFACTION AND RELEASE OF CLAIM The undersigned, Kathy LoRocco, Agent for HOUSEHOLD RETAIL SERVICES, has received apro-rata distribution of $119.92 equal to 11.36%, satisfying the claim filed in this proceeding on behalf of the Creditor to the extent of insolvency of the estate. This satisfaction and Release of Claim is executed to acknowledge discharge of the claim and to release the estate and personal representative from all further liability in respect to the date of death liability on account number 0000061390220459. Executed this February 5, 2004. :~ ~. ~,~ ~ ~ ..: :~..~ ~; ,~, HOUSEHOLD RETAIL SERVICES Claimant J ~, Cc.~ BY~ I ~-i 41. ~~(~5~~~~: KATHY LOROCCO, Agent Estate Recoveries, Inc. P.O. Box 24566 Baltimore, MD 21214 . N W ~ Y cerUly that written notice of be of tt+is Statement M Proposed d~bution, end o/ the date. time and ptaoe when the same wMl be preserNed to ttte Court for oonbnneltion end d lFte bM day b the w-Itten ab~ectlons b sdd 8lsernent d Proposed DlsbbtAton, frets been flw'en b eresy unpaid claimant and b every other pemort taiowrf b tf to aot:ourtlerat b have or c~atrn an tnlsr~Bet In the e6ta19 E1EZ txedbr, berseAdary. heir or rsext of tM. A copy of add 23taAement was itaduded wilts the notfoe. __ O C1 H id C Z ro3 xr~y ~r~x Z ,~ r~ cn r -~~ Zo ndC 0 Cf7~. ;U O H C O Z ~ d H H ~-C (~ C~ O --i 3 v~ ro 3 H ~ O o Z Z ro r ~:. fr ;~ .~ ;,; -~_ r4 i ~~ -~T ~~ ~i.r f~ ,~ :. A ~ ~i ,~ .~ -~_ ~ .u ~ :~ t "G F7 ~ ,;} :, .:, e.: :a i; i (a. ,~.~, ~~~~~~~~ ~ ~~~ m ~~~$~ ~~~sg~~~ .~~~~~ ~ ~~~ ~ a~ ~ ~ ~ ~~~~g ~. '~ ~~ ~s 7 ~ ~ -0 ~~ ~' /7-/06 - ?" v , ~EV - WiD EX + (6-00) OFFICIAL USE ONLY COMMONWEALTH OF PENNSYLVANIA REV-1500 DEPARTMENT OF REVENUE DEPT. 280601 INHERITANCE TAX RETURN FILE NUMBER HARRISBURG, PA 17128-0601 RESIDENT DECEDENT c2/ 0.:. ID97 COUNTY CODE YEAR NUMBER DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER Jordan Jean G 146-18-8758 DECE- DATE OF DEATH (MM-DD-YEAR) TDATE OF BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DUPLICATE DENT 11/23/2002 WITH THE REGISTER OF WILLS (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER - - ~ B 3. Remainder Return CHECK 1. Original Return ~' Supplemental Return (date of death prior to 12-13-82) APPRO- 4. Limited Estate 4a. Future Interest Compromise 5. Federal Estate Tax Return Required ~ale of death after 12-12-82) PRIATE 6. Decedent Died Testate 7. ecedent Maintained a LIving Trust 0 8. T ctal Number of Safe Deposit Boxes (Attach copy of Will) ~t1ach a copy of Trustl BLOCKS 9. Litigation Proceeds Received 10. pausel Poverty Credl (date of death between 0 11. Election to tal< under Sec. 9113(A) 12-31-91 and 1-1-95) {Attach 8ch OJ JJli$$mlj:j!lMtl$tljileQMi!ijiitlibjllij!ie~$ilRRl1)~lfilWwlpgijj,AlItAliIN!'QaMAtlblij[$!lbU41jil\'illitlmftebid; NAME COMPLETE MAILING ADDRESS COR- Steven J. Schiffman, Esq. 2080 Ling1estown Road, Suite 201 RE- FIRM NAME (If Applicable) Harrisburg, PA 17110 SPON DENT SERRATELLI, SCHIFFMAN, ET AL. TELEPHONE NUMBER 717-540-9170 OFFICIAL USE ONLY 1. Real Estate (Schedule A) (1) 0 2. Stocks and Bonds (Schedule B) (2) 0 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) 0 4. Mortgages & Notes Receivable (Schedule D) (4) 0 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) (5) 8,197 6. Jointiy Owned Property (Schedule F) 0 Separate Billing Requested (6) 0 RECA- I PITULA- 7. Inter-Vivos Transfers & Miscellaneous TION Non-Probate Property (Schedule G or L) (7) 21,401 8. Total Gross Assets (total Lines 1-7) (8) 29,598 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 4,993 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 6,219 11. Total Deductions (total Unes 9 & 10) (11) 11,212 12. Net Value of Estate (Une 8 minus Line 11) (12) 18,387 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax (13) 0 has not been made (Schedule J) 14. Net Value Subject to Tax (Une 12 minus Line 13) (14) 18,387 SEE INSTRUCTIONS ON PAGE 2 FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (aX1.2) 0 X.O ~O(5) 0 TAX 16. Amount of Une 14 taxable at lineal rate 21,401 X .0 ~4(l6) 963 COMPU- 17. Amount of Line 14 taxable al sibling rate 0 X .12 (17) 0 TATION 18. Amount of Une 14 taxable at collateral rate 0 X .15 (18) 0 19. Tax Due (19) 963 20. 0 tl:$a::;~H!1tl~!l'!i!OUAjij~I'redQ~lijljjfiij!ilWi'it!OF~~fWiiYMiSI,\Ttl """""""""""'''''''''''''''''''\'''.',','41i'!i!e,$UIlE'T(iiAN$WEl'l'AIXl:iUE$1JON$iONJ!.M:;ei<l.ANDillrecHEcKJiIA1H{j{i""'" o PA 15001 NTF 29755 Copyright 2000 Greatland/Nelco LP ~ Forms Software Only Estate of, Name Address Tax ID 146-18-8758 Executors (Page 1) John S. Jordan 1808 Signal Hill Drive Mechanicsburg, PA 17050- 155-46-2716 PA REV, 1500 EX (6-00) D Page 2 ecedent's Comnlete Address: STREET ADDRESS 102 November Drive Cumberland CITY I STATE I ZIP Camp Hill PA 17011 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 963 o 915 48 Total Credits (A + B + C) (2) 963 3. Interest/Penalty jf applicable D. Interest E. Penalty o o Total Interest/Penalty (0 + E) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + SA. This is the BALANCE DUE. ........................................................................................................................................:..:..:..:..:.:..:..:.:..:..:.:.....:..~....:..:~......k....e.. ....C.......he......c...k......p.....a....y...a...b.....I.e.....to......:......R.......E........G........I....7.......T.....:....E.........R.............O.....~.......w..........I.b:;\!'GENT ,.:.,.,.:.:.,.,.,.,.,.;.:.,.;.,.,.:.:.,.:.:.,.,.:.:.,.:.;.,.:.,.,.:.;.:.,.,.,.:.;.,.:.;.:.:.;.,.:.,. ?{:~:::t::::::~:t::::::::}f:{::::::;~:;:~:~:;:~;~:)~:;:~;~:}~{;}L::;::,:::::<::<:;:;:;:;:;:;:;:;:;:;::::::::::::::::::::.:::::::::::::::::::::::::::::::::::::(::...::;:::::::::::;:::::;::::;:::::::.: :.:.;.:.:<.:.::::;::;:::::,:::::::::::::~:;::,.:.:........ PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. (3) o (4) (5) (SA) (5B) o o o o Did decedent make a transfer and: 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; or. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . d. receive the promise for life of either payments, benefits or care? ...... . . . . . . . . . . . . . . . . . . . 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? . . . . . . . . . . . . . 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? . . . . . . . . . . . . . . . . . , . . . . , . , , . . . . . . . . . . . . . . . . . . . . . . . , . . , . .. ~ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties of erjury, I declare tha ve mined this return~ including aCC'')i~ 'oanying schedules and statements, and to the best of my kn,?wledge and , . is tr ,carr ct nd campi . Declaration aT prepar".:: ,~I~Lt:;' '~Han the personal representative is based on information of which re a[ as an n ed e. ___"....,.._.__....._. SIGNATU OF PER SPO SI LE FOR FI IN ETURN Yes No ~ I B ~ o 11 DATE - -(J~ PA 17050 Ling1estown Road, Suite 201 Harrisburg, PA 17110 ':::::::::::':"::-::'::'::'::::"::':':::':':::':':::':::::':::::':::::':::::'::":':::::'::::::::::::::::::::::::::::::::::::;::':::::'::::::::'::':::::':::::':::::::':::':::::::::::::::::':'?:::::::: ::::::::::::::::::::::::::::::;:::::;::':::::::::::::'::;::':::::'::;::,::::::::::;::,:::,:-:.:...-." "'or' da ie-;; of' '(j'ea i'Ii' on' Or'8 f ier' j(ji y' '; ~'195)4' and 'before' ja:nuar'Y"1:' i-'185',' i 'Ii'e' ia;'; '':aie- 'Impose;t~'~"I"t;'~"'~;t"~;;':i'~;'~'f' ij.'ilnsfer's' to' o~"f-;:;~"'i'h;..~;~..~ti'h;"~~~~'i~i~9"~p-;:;~~';"i'~'i%... [72 P.S. Ii 9116 (a) (1.1) (i)). For dates of death on or after January 1, 1995, the tax rate is Imposed on the net value of transfers to or lor the use olthe surviving spouse Is 0% [72 P.S. Ii 9116 (a) (1.1) (ii)]. The statute l'InA" nnt Av..mnt a transfer toa surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are stili 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.19116(a)('.2IJ. 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.1i 9116(1.2) [72 P.S.1i9116(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. 19116(a)(1.3)]. A sibling Is defined, under Section 9102, asan Individual who has at least one parent in common with the decedent, whether by blood or adopllon. o PA 15002 NTF 29756 Copyright 2000 13reatJand/Nelco LP - Forms Software Only REV-150B EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Jean G. Jordan Include proceeds of litigation & date proceeds were received by the estate. All prop. jointly-owned with right of survivorship must be disclosed on Sch. F. SCHEDULE E CASH, BANK DEPOSITS. & MISC. PERSONAL PROPERTY FILE NUMBER ITEM NO. 11. London Blue Topaz Ring DESCRI PTION VALUE AT DATE OF DEATH o The decedent's will provided for the specific devise of this ring to her granddaughter; however, the ring did not exist at the time of death. 2 Outlook Pointe at Creekview 1,127 (Refund) 3 Pennsylvania Department of Revenue 89 (2001 Pennsylvania Personal Income Tax Refund) 4 Personal Property 100 The Decedent was residing in a nursing home at the time of her death and had limited personal property. The cost of an appraisal was not warranted. 5 PNC Bank Checking Account #50-0081-3338 6,827 The reported date of death value of this account was $7246.66. The difference in the date of death value to the actual value is attributable to checks which did not clear at the time of death in the amount of $419.80. 6 Senior Blue 54 (Refund of Medical Insurance) 9 PA15081 NTF 10875 Copyright 1999 Greatland/Nelco LP - Forms Software Only TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 8,197 REV-1S10 EX + (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Jean G. Jordan SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY FILE NUMBER This schedule must be completed and filed jf the answer to any of questions 1 through 4 on the reverse side of the REV -1500 COVER SHEET is yes. ITEM NO. 11. DESCRIPTION OF PROPERTY INCLUDE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECD & DATE OF TRANSFER. ATTACH COPY OF THE DEED FOR REAL ESTATE. Glenbrook Annuity DATE OF DEATH VALUE OF ASSET 21,401 %OF DECD'S INTEREST 100.000 EXCLUSION (IF APPLICABLE) o TAXABLE VALUE 21,401 Beneficiaries in Equal Shares: John S. Jordan, Son Edward H, Jordan, Son This is a non-probate asset. The decedent's will did not contain a provision which would allow payment of the tax from her Estate. Therefore, the beneficiaries are responsible for payment of the tax on the entire amount since they did not personally pay for any Estate expenses listed as deductions. TOTAL (Also enter on line 7, Recapitulation) $ 9 PA15101 NTF 10877 (If more space is needed, insen additional sheets of the same size) Copyright 1999 Greatland/Nelco LP - Forms Software Only 21,401 REV-151.1EX+ (1-97) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Jean G. Jordan SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FI LE NUMBER Debts of decedent must be reported on Schedule I. ITEM NO. A. 1. 1 DESCRIPTION AMOUNT FUNERAL EXPENSES: Laurel Memorial Park Pomona, NJ Opening and Closing of Grave 475 2 Neill Funeral Home, Inc. 2,321 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) John S. Jordan Social Security Number(s)/EIN No. of Personal Representative(s) Street Address 1808 Signal Hill Drive CityMechanicsburg State PA Zip 17050 500 Year(s) Commission Paid: 2003 2. 3. Attorney Fees 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 1,000 4. Probate Fees 91 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. 1 CUmberland Law Journal (Estate Advertisement) 75 2 John S. Jordan (Reimbursement of Costs - Mileage re: interment) 143 3 Monument (Grave Monument) 289 Total from continuation paqes 99 9 PA15111 NTF 10B78 Copyright 1999 Grealland/Nelco LP - Forms Software Only TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 4,993 Item Noo 4 5 Schedule H part 2 (Page 2) Estate of: Jean Go Jordan Description Amount PNC Bank (Check Charges) The Sentinel (Estate Advertisement) Total (Carry forward to main schedule) 28 71 99 REV-1512 EX + (1-97) COMMONWEALTH Of PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Jean G. Jordan Include unreimbursed medical expenses. ITEM NO. 1. 1 Boscov' s SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS FILE NUMBER DESCRIPTION AMOUNT 465 2 Citifinancial (Credit Card) 2,825 3 Claremont Nursing and Rehab Center 1,752 4 Household Retail Services, USA (c/o Estate Recoveries, Inc.) 1,055 5 Verizon 121 9 PA 15121 NTF 10874 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 6,219 Copyrighl1999 Greatland/Nelco LP . Forms Software Only REV-1513 EX+ (9-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARI ES FILE NUMBER Jean G. Jordan NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] RELATIONSHIP TO DECEDENT AMOUNT OR SHARE Do Not List Trustee(s) OF ESTATE 1 ,. John S. Jordan 1808 Signal Hill Drive Mechanicsburg, PA 17050 Son 10,701 2 Edward H. Jordan, Jr. p613 Pinehurst Way Mechanicsburg, PA 17050 Son 10,700 ENTER DOLLAR AMTS. FOR DISTRIBS. SHOWN ABOVE ON LINES 15 THROUGH 18 AS APPROPRIATE ON REV- 1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHiCH AN ELECTION TO TAX IS NOT BEING MADE ,. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS ,. TOTAL OF PART II -- ENTER TOTAL NON-TAXABLE DISTRIBS. ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) o o PA15131 NTF 33293 Copyright 2000 Greatland/Nelco LP - Forms Software Only 11'" ....., .".. . ' , ~~\) i.i ."fl~"" ';:f~.' .....~...........{,.,' ';, ""->~~., ~ ~.'~~, ~ -"'- ~, ~<....~' fi<'liil,,~~: ~;} .~~.~~ ).V.: . , J ~'" ~ "'-;I' "Ii? .' . , ('~.. ~,-". t ....It;I .. .~.... ...~ ~ ,,' ........... .'~\ Il'1 ~ ' " Register of Wills of CUMBERLAND County, pennsylvania Certificate of Grant of Letters No. 2002-01097 PA No. 21-02-1097 ESTATE OF JORDAN JEAN G \LAbl, rlKbl, M1UUL~) Late of CAMP HILL BOROUGH CUMb~K~~0 CUUN1Y/ Deceased WHEREAS, on the 5th dated December 19th 1997 was admitted to probate as the last will of JORDAN JEAN G (LA~l, ~lKbl, M1UULb) Social Security No. 146-18-8758 day of December 2002 an instrument late of CAMP HILL BOROUGH CUMBERLAND County, who died on the 23rd day of November 2002 and, WHEREAS, a true copy of the will as probated is annexed hereto. THEREFORE, I, MARY C. LEWIS , Register of Wills in and for the County of CUMBERLAND in the Commonwealth of Pennsylvania, hereby certify that I have this day granted Letters TESTAMENTARY to JORDAN JOHN S who has duly qualified as Executor (rix) and has agreed to administer the estate according to law, all of which fully appears of record in my Office at CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNSYLVANIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my Office the 5th day of December 2002. ~mN-h, k\L:k ~nM.~~~I' .L3~ \ egls r s , * *NOTE* * ALL NAMES ABOVE APPEAR (LAST. FIRST. MIDDLE) LAST WILL AND TESTAMENT ~I-O~-Ioq~ I, JEAN G. JORDAN, of 102 November Drive, Apartment No.2, Camp Hill, Cumberland County, Pennsylvania 17011, do hereby make, publish and declare this to be my last will and testament, hereby revoking all wills heretofore made by me. 1. I direct my personal representative to pay all of my debts, funeral and administrative expenses as soon as convenient after my decease. 2. I authorize and empower my personal representative to sell any realty and/or personalty owned by me at my death and not specifically devised or bequeathed herein, at public or private sale or sales and to give good and sufficient deeds and/or bills of sale therefor, in fee simple, as I could do if living. My representative is authorized and empowered to engage in any business in which I may be engaged at my death, for such period of time after my death as seems expedient to said representative. 3. I give, devise and bequeath all of my estate of whatever nature and wherever situate as follows: A. My London Blue Topaz ring to my granddaughter, Amanda L. Jordan; and all the rest, residue and remainder of my estate as follows: B. 60% to my son, John S. Jordan, or if he is deceased, then to his children, share and share alike, the child or children of any deceased child taking the share their parent would have taken if living; and C. 40% to my son, Edward H. Jordan, or if he is deceased, then to his children, share and share alike, the child or children of any deceased child taking the share their parent would have taken if living. 4. I nominate and appoint John S. Jordan to be the personal representative of my estate, to serve without bond. If he cannot or does not serve, then I appoint Edward H. Jordan to be the substitute personal representative, also without bond. 5. I suggest that my personal representative retain the services of Harold S. Irwin, III, Carlisle, Pennsylvania in the settlement of my estate. IN WITNESS WHEREOF, I have hereunto set my hand and seal this /97' day of December, 1997. UnrY"Y"l ~n '11). Jo I1fl (SEAL) Je4)G.-JO~~NOlY "(I "VIi Signed, sealed, published and declared by the above-named person as and for a last will and testament, in our presence, who at said person's request, in said person's presence and in the presence of each other have hereunto set our names as subscribing witnesses. ~a iJ 8cuJ;UUJ ~~. >. ..d _,.,"V<.., ACKNOWLEDGMENT AND AFFIDA VIT WE, JEAN G. JORDAN, HEATHER A. BARBOUR and GAY L. IRWIN, the testatrix and witnesses respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the testatrix signed and executed the instrument as her last will and that she had signed willingly, and that she executed it as his free and voluntary act for the purpose herein expressed, and that each of the witnesses, in the presence and hearing of the testator, signed the will as a witness and that to the best of their knowledge the testatrix was, at that time, eighteen years of age or older, of sound mind and under no constraint or undue influence. JEAH~A~ yWt- 4~~ HEATHER A. BARBOUR ~~ h~ GA L. WIN COMMONWEALTH OF PENNSYLVANIA :55: COUNTY OF CUMBERLAND Subscribed, sworn to and acknowledged before me by JEAN G. JORDAN, the testatrix herein, and subscribed and sworn to before me by HEATHER A. BARBOUR and GAY L.IRWIN, witnesses, this /tf1' day of December, 1997. .. .~ l.: L STATUS REPORT UNDER RULE 6.12 Name of Decedent: Jean G. Jordan Date of Death: 11-23-2002 Will No. 2002-01097 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: 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 x No_ b. The separate Orphans' Court No. (if any) for the personal representative's account is: O1-13-2004 c. Did the personal representative state an account informally to the parties in interest? Yes_ No x d. Copies of receipts, releases, joinders and approvals of fo al off' formal accounts may be filed with the Clerk of the Orphans' Court and be att ~ eport. .~. __ Dated: ~ ~ ' G' ~ '" _. STEVEN J. SCHIFFMAN, ESQ. 2080 Linglestown Rd., Suite 201 Harrisburg. PA 17110 Address (7171540-9170 Telephone Number Capacity: _ Personal Representative x Counsel for Personal Representative Representative