HomeMy WebLinkAbout06-03-15 (2) 1505610143
REV-1500 EX(02-11) '
PA Department of Revenue OFFICIAL USE ONLY
p pennsylvania County Code Year File Number
Bureau of Individual Taxes DEPARTMENT OF REVENUE
PO BOx.280601 INHERITANCE TAX RETURN 21 14 0914
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
09 04 2014 02 24 1929
Decedent's Last Name Suffix Decedent's First Name MI
HERTZ EUGENE H
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
O 1. Original Return 2, Supplemental Return 3. Remainder Return(Date of Death
Prior to 12-13-82)
4. Limited Estate 4a Future Interest Compromise ❑ 5. Federal Estate Tax Return Required
(date of death after 12-12-82)
6 Decedent Died Testate 7. Decedent
Attache Copy of Trust) Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) V
g. Litigation Proceeds Received 10.betweenP2v31 SCrae ditiDatses�f Death 11 Election to tax under Sec.9113(A)
(Attach Schedule O)
CORRESPONDENT.THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
MICHAEL L BANGS 717 730 7310
REGISTER OF WILLS USE ONLY
C=
First Line of Address -I 701 rn
429 SOUTH 18TH STREET �?
1.9 i
Second Line of Address 1>
- W
DATE"FILED -
City or Post Office State ZIP Code
CAMP HILL PA 17011co
# J �
_..
° C.J
Correspondent's e-mail address: mikebangs@verizon.net
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.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE
—,w Susan M.Wagner
ADDRESS 11
982 Limekiln Road, New Cumberland, PA 17070
SIGNATURE OF PREPARER OTHER T AN PRESENTATIVE DATE
rvL,14 Z �� Michael L. Bangs 6/af j s
ADDRESS b
429 South 18th Street, Camp Hill, PA 17011
Side 1
1505610143 1505610143 J
0
1505610243
REV-1500 EX Decedent's Social Security Number
Decedent's Name: Hertz, Eugene H.
RECAPITULATION
1. Real Estate(Schedule A)........................... ........... ........................... .................. 1 200 , 576 . 15
2. Stocks and Bonds(Schedule B)......... ................... ......................... ..................... 2. 20 , 502 . 11
3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C)......... 3.
4. Mortgages&Notes Receivable(Schedule D)........................................................ 4.
5. Cash,Bank Deposits 8.Miscellaneous Personal Property(Schedule E)............... 5. 119, 489. 70
6, Jointly Owned Property(Schedule F) El Separate Billing Requested............ 6.
7. Inter-Vivos Transfers&MiscellaneousProbate Property
(Schedule G) It Separate Billing Requested............ 7. 787 , 102 . 73
8, Total Gross Assets(total Lines 1 through 7)..._..--.... .................-... ........... 8. 1 , 127 , 670 . 69
9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 44 ,335. 80
10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule 1)............................ 10. 2 , 575 . 33
11. Total Deductions(total Lines 9 and 10)................................ ....................... ....... 11. 46, 911 . 13
12. Net Value of Estate(Line 8 minus Line 11).............. ............... ..... 12. 1 , 080 , 759. 56
13. Charitable and Governmental Bequests/See 9113 Trusts for which
an election to tax has not been made(Schedule J)........... 13.
14. Net Value Subject to Tax(Line 12 minus Line 13)............................................... 14. 1 , 080, 759 . 56
TAX COMPUTATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116
(a)(1.2)X.00 15. 0 . 00
16. Amount of Line 14 taxable 1 , 080 , 759 . 56 16. 48 , 634 . 18
at lineal rate X .045
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
119. TAX DUE......... ................................... ........... 19. 48 , 634 . 18
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. El
Side 2
1505610243 1505610243
REV-1500 EX Page 3 File Number 21-14-0914
Decedent's Complete Address:
DECEDENT'S NAME
Hertz, Eugene H.
STREET ADDRESS
907 East Coover Street
CITY STATE ZIP
Mechanicsburg PA 17055
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 48,634.18
2. Credits/Payments
A. Prior Payments 45,000.00
B. Discount 2,368.42
Total Credits(A +B) (2) 47,368.42
,3. Interest (3)
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4)
Check box on Page 2,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. (5) 1,265.76
Make Check Payable to: REGISTER OF WILLS, AGENT.
r— -
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;or............................................................................................................... H ❑
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?.................................................................................................................. ❑ ❑
4F 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 January 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.
li
Rev-1502 EX+ 01.10)
SCHEDULE A
pennsylvania REAL ESTATE
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Hertz, Eugene H. 21-14-0914
All real property owned solely or as a tenant in common must be reported at fair market value.Fair market value is defined as the price at which property would be
exchanged between a willing buyer and a willing seller,neither being compelled to buy or sell,both having reasonable knowledge of the relevant facts.
Real property that is jointly-owned with right of survivorship must be disclosed on schedule F.
Attach a copy of the settlement sheet if the property has been sold
Include a copy of the deed showing decedent's interest if owned as tenant in common.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Real Estate-907 E.Coover Street, Mechanicsburg, PA. Sold on 10/23/14(see HUD attached) 200,576.15
TOTAL(Also enter on Line 1, Recapitulation) 200,576.15
(If more space is needed,additional pages of the same size)
Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule A(Rev.01-10)
Rev-7503 EX+(6-98)
SCHEDULE B
STOCKS & BONDS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Hertz, Eugene H. 21-14-0914
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM CUSIP VALUE AT DATE
NUMBER NUMBER DESCRIPTION UNIT VALUE OF DEATH
1 352 shares of CenturyLink,Inc. -CTL common stock 41.47 14,597.44
2 523 shares of Windstream Holdings, Inc.-WIN common 11.29 5,904.67
stock
TOTAL(Also enter on Line 2, Recapitulation) 20,502.11
(If more space is needed,additional pages of the same size) ,
Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule B(Rev.6-98)
Rev-1508 EX+(11-10)
SCHEDULE E
pennsylvania CASH, BANK DEPOSITS, & MISC.
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Hertz, Eugene H. 21-14-0914
Include the proceeds of litigation and the date the proceeds were received by the estate,
All property jointly-owned with the right of survivorship must be disclosed on schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Century Link dividend 190.08
2 Conerstone Federal Credit Union-Checking account 25,047.80
3 Cornerstone Federal Credit Union -Savings Account(#12247) 127.50
4 Cornerstone Federal Credit Union-Savings account(#82247) 49,831.27
5 Cornerstone Federal Credit Union-Money Market account 21,965.48
6 Long term care refund from John Hancock 868.58
7 Members 1st Federal Credit Union-Regular savings 711.99
8 Members 1st Federal Credit Union-Money Management account 19,491.56
9 Refund from Country Meadows 505.00
10 Refund from PPL Electric 18.94
11 Refund of homeowners insurance 470.00
12 Windstream -stock dividend 2/10/15 130.75
13 Windstream stock dividend-11/5/14 130.75
TOTAL(Also enter on Line 5, Recapitulation) 119,489.70
(If more space is needed,additional pages of the same size)
Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule E(Rev. 11-10)
Rev-1510 EX+(08.09)
SCHEDULE G
pennsylvania INTER-VIVOS TRANSFERS AND
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Hertz, Eugene H. 21-14-0914
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE
NUMBER THE DATE ONAME
^TRANSFERSATTAck THEIR COPY OF THE DEED FOHIP TO R REAL ESTATE. VALUE OF ASSET T AND INTEREST (IF APPLICABLE) VALUE
1 Jackson National Life Insurance Company-annuity 207,539.56 207,539.56
contract
2 John Hancock-Annuity Contract 2637363 128,774.89 128,774.89
3 John Hancock-Annuity Contract FX06007543 271,782.34 271,782.34
4 Phoenix Life Insurance Company-Annuity Contract 98,625.21 98,625.21
5 Vanguard-PA LT Tax-Exempt Admiral Fund 80,380.73 80,380.73
TOTAL(Also enter on Line 7, Recapitulation) 787,102.73
(If more space is needed,additional pages of the same size)
Copyright(c)2009 form software only The Lackner Group,Inc. Form PA-1500 Schedule G(Rev.08-09)
REV-1511 EX+(10-09) SCHEDULE H
pennsylvania
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
I INHERITANCE TAX
RESIDENT DECEDENT RETURN ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Hertz, Eugene H. 21-14-0914
Decedent's debts must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
See continuation schedule(s) attached 12,576.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Susan M.Wagner
Street Address 982 Limekiln Road
city New Cumberland State PA zio 17070
Year(s)Commission Paid 15,000.00
2. Attornev's Fees Michael L. Bangs 15,000.00
3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation)
Claimant
Street Address
City State ZiD
Relationship of Claimant to Decedent
4. Probate Fees 495.50
5. Accountant's Fees 1,000.00
6. Tax Return Preparer's Fees
7. Other Administrative Costs 264.30
See continuation schedule(s) attached
TOTAL(Also enter on line 9, Recapitulation) T— 44,335.80
Copyright(c)2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev. 10-09)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Hertz, Eugene H. 21-14-0914
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Expenses
1 Myers Harner Funeral Home 11,486.00
2 Resurrection Cemetery 1,090.00
H-A 12,576.00
Other Administrative Costs
3 Cumberland Law Journal-estate advertisement 75.00
4 The Patriot News Co. -estate advertisement 189.30
H-67 264.30
Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.6-98)
Rev-1512 EX+(12-08)
SCHEDULE 1
pennsylvania DEBTS OF DECEDENT,
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN MORTGAGE LIABILITIES AND LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Hertz, Eugene H. 21-14-0914
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 Comcast Cable 53.25
2 Discover Bank 538.10
3 Holy Spirit Medical Group 39.93
4 Home Instead Care 367.13
5 PA Retina Specialists 13.31
6 PA Retina Specialists 28.03
7 United States Treasury-2014 income tax due 1,218.00
8 United Water Company 30.33
9 United Water-final bill 21.25
10 UPCA Urology 4.56
11 UPCA Urology of Central PA 3.00
12 Verizon 11.91
13 Walgreens Pharmacy 246.53
TOTAL(Also enter on Line 10, Recapitulation) 2,575.33
(If more space is needed,additional pages of the same size)
Copyright(c)2008 form software only The Lackner Group, Inc. Form PA-1500 Schedule I(Rev. 12-08)
REV-1513 EX+(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Hertz, Eugene H. 21-14-0914
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(S)RECEIVING PROPERTY DECEDENTDo Not List Tru t (Words) ($$$)
� TAXABLE DISTRIBUTIONS [include outright spousal
distributions,and transfers
under Sec.9116(a)(1.2)]
Sandra J.Mannherz Daughter one-third
1401 N. Barnegat Avenue
Surf City, NJ 08008-6428
Cynthia A. Poole Daughter one-third
4379 Green Park Drive
Mount Joy, PA 17552
Susan M.Wagner Daughter one-third
982 Limekiln Road
New Cumberland, PA 17070
Total
Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet as appropriate.
NON-TAXABLE DISTRIBUTIONS:
II. A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11 -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule J(Rev. 01-10)
OMB Approval No.2502-0265
j•a A. Settlement Statement (HUD-1)
FINAL
IB.Type of ..
1.❑FHA 2,❑RHS 3.❑Conv.Unins. 6.File Number. 7.Loan Number. 8.Mortgage Insurance Case Number.
14-2447GC
4.❑VA 5.❑Conv.Ins.
C.Note:This form is furnished to give you a statement of actual settlement costs.Amounts paid to and by the settlement agents are shown,Items marked
'(p.o.c)'were paid outside the closing;they are shown here for informational purposes and are not Included in the totals.
D.Name&Address of Borrower: E.Name&Address of Seller. F.Name&Address of Lender.
Carolyn L.Hoffman Susan M.Wagner,Executrix of the Estate of Eugene H.
241 Mumper Lane,Diusburg,PA 17019 Hertz
907 E Coover Street Mechanicsburg,PA 17055
G.Property Location: H.Settlement Agent I.Settlement Date:10/23(2014
907 E Coover Street Guardian Transfer Corporation Disbursement Date:1 0/2 312 01 4
Mechanicsburg,PA 17055 4075 Market SL,Camp Hill,PA 17011
Mechanicsburg Borough
Phone:717-909-4700 Fax 717-723-4585
Place of Settlement TideExpress
4075 Market Street Camp Hill,PA 17011 Printed I Ot=2014 at 4:11 pm
by AL
Tsum-marV of Borrower's Transaction I- I
100. Gross Amount Due from Borrower 400. Gross Amount Due to Seller
101. Contract sales price 213,950.00 401. Contract sales price 213,950.00
102. Personal property 402. Personal property
103. Settlement charges to borrower Vine 1400) 4,190.50 403.
104. 404.
105. 405.
Adjustments for items paid by seller in advance Adjustments for items paid by seller in advance
106. CityR taxes to 406. City/town taxes to
107. County taxes 10232014 to 12131/2014 219.35 407. County taxes 10/23/2014 to 12131/2014 219.35
108. School taxes 10232014 to 06/30/2015 1,737.02 408. School taxes 1023/2014 to 06/30/2015 1,737.02
109, Sewer/Refuse O/NID 10232014 to 12/312014 107.28 409. Sewer/Refuse 0/N/D 1023/2014 to 12/312014 10728
110. 410.
111. 411.
112. 412.
120. Gross Amount Due from Borrower 220,204.15 420. Gross Amount Due to Seger 216,013.65
200. Amounts Paid by or in Behalf of Borrower 500. Reductions In Amount Due to Seller
201. Deposit or earnest money 10,000.00 501. Excess deposit(see instruC00 s)
202. Principal amount of new loan(s) 502. Settlement charges to seller Vine 1400) 15,437.50
203. Existing s taken subject to 503. Existing W s taken subject to
204, 504. Payoff of first mortgage loan
205. 505. Payoff of second mortgage loan
206. 506•
207. 507•
208. 508.
209. 609.
Adjustments for items unpaid by seller Adjustments for items unpaid by seller
210. CityRown taxes to 510. Citykovm taxes to
211. County taxes to 511. County taxes to
212. School taxes to 512. Scimol taxes to
213. 513.
214, 514.
215. 515.
216. 516.
217. 517.
218. 518.
219 519.
220. Total Paid b!for Borrower 10,000.00 520. Total Reduction Amount Due Seller 15,437.50
300. Cash at Settlement fromito Borrower 600. Cash at Settlement tolfrom Seller
301. Gross amount due from borrower pine 120) 220,204.15 601, Gross amount due to seller(Gne 420) 216,013.65
302, Less amounts paid by/for borrower Vine 220) 10,000.00 602. Less reductions in amount due saber pine 520) 15,437.50
303. Cash ❑X From ❑ To Borrower 210,204.15 603. CashX❑ To ❑ From Seller 200,576.15
Oblam,abatLL apme«v.W OUS takd nmWr.WodddM/Wyb-M1.0 Hadrla-.b-rdYPy.TMib bp,oyrG�y yaA-b•RESPA�py.,b pW-YpnvWl Hq-iOm aYph
w s. .P-
Previous editions are obsolete Page 1 o 3 HUD-1
700. Total Real Estate Broker Fees S13,482.00 Paid From Paid From
Division of commission Olne 700 as follows: Borrower's Seller's
701• $6,713.50 to Century 21 Realty Services Funds at Funds at
702• $6,768.50 to Coldwell Banker Homestead Group Settlement Settlement
703. Commission paid at settlement 350.00 13,132.00
800. Items Payable in Connection with Loan
801. Our origination charge (Includes Origination Pant 0.000%or$0.00) $ (from GFE#1)
802. Your credit or charge(points)for the specific interest rate chosen $ (from GFE#2)
803. Your adjusted origination charges (from GFE A)
804• Appraisal fee to from GFE#3
805. Credit report to from GFE#3
806. Tax service to from GFE#3
807. Flood certification to from GFE#3
808. to
900. Items Required by Lender to be Paid in Advance
901. Daly interest charges from from 10/23/2014 to 11/01/2014 @$$0.00/day (from GFE#10)
902. Mortgage insurance premium for months to (from GFE#3)
903. Homeowner's insurance for ears to (from GFE#11)
904. months to from GFE#11
1000.Reserves Deposited with Lender
1001. Initial deposit for your escrow account (from GFE#9)
1002.Homeowners insurance 2 months Ca$ 0.00/month $
1003.Mortgage insurance 2 months @$ 0.00/month $
1004.Property taxes 2 months Q$ 0.00/month $
1005• months 0$ 95.31/month $
1006.Assessments months a$ 210.50/month $
1007.Aggregate Adjustment $
1100.Title Charges
1101.Title services and lender's title insurance $ from GFE#4 5.00
1102. Settlement or dosing fee to $
1103.Owner's title insurance-First American Title Insurance Company $ from GFE#5 1,617.00
1104. Lenders title insurance-First American Title Insurance Company $
1105. Lenders title policy limit$0.00 Lenders Policy
1106.Owners title policy limit$213,950.00 Ovmees Policy
1107.Agent's portion of the total title insurance premium $1,374.45
to Guardian Transfer Corporation
1108. Underwriters portion of the total title insurance premium $242.55
to Forst American Title Insurance Company
1109.Notary Fee to Guardian Transfer $5.00 15.00
Corporation
1110.Tax Certification Reimbursement to Guardian Transfer 10.00
Corporation
1200.Government Recording and Transfer Charges
1201.Government recording charges $ (from GFE#7) 79.00
1202. peed$79.00 Mortgage$ Release$
1203.Transfer taxes $ (from GFE#8) 2,139.50
1204.City/County tax/stamps Deed$2,139.50 M $
1205.State Taxtstamps Deed$2,139.50 M $ 2,139.50
1206. Deed$ Mortgage$
1207. $
1300.Additional Settlement Charges
1301.Required services that you can shop for (from GFE#6)
00
1302.Sewer/Refuse OHD to Mechanicsburgh Office 141.
1303. to
1304, to
1305. to
Mr,jr r ,- r r 4,190.50 15,437.50
'Paid outside of dosing by(B)orrower,(S)eller,(L)ender,(I)nvestor,&o(IQer."Credit by tender shown on Page 1.-Wd by seller sham on page 1.
Previous editions are obsolete Page 2 of 3 HUD-1
Signature Page I
HUD CERTIFICATION OF BUYER AND SELLER
I have carefully reviewed the HUD-1 Settlement Statement and to the best of my knowledge and belief,it is a true and accurate statement of all receipts and
disbursements made on my account or by me in this transaction I further certify that I have received a copy of the HUD-1 Settlement Statement
Carolyn L Hoffman
Susan M.Wagner,Executrix df the Estate)Iaf Eugene H.Hertz
Settlement Agent
The HUD-1 Settlement Statement which i have prepared Is a true and accurate account of this transactioa t have caused or will cause the funds to be
disbursed in accordance with this statement
jaa"& lij oh
SETTLEMENTAGENT DATE 1
WARNING:IT IS A CRIME TO KNOWINGLY MAKE FALSE STATEMENTS TO THE UNITED STATES ON THIS OR ANY SIMILAR FORM.PENALTIES UPON
CONVICTION CAN INCLUDE A FINE AND IMPRISONMENT.FOR DETAILS SEE TITLE 18:U.S.CODE SECTION 1001 AND SECTION 1010.
previous editions are obsolete Page 3 of3 HUD-1
John Hancock Life Insurance Company(U.S.A.)
John Hancock Annuities Service Center
30 Dan Road,Suite 55444,Canton,MA 02021-2809
Mailing Address:PO Box 55444,Boston,MA 02205-5444
(877)543-2363
www.jhannuities.com
December 18,2014
Michael L.Bangs,Esquire
Bangs Law Office,LLC
429 South 18`h Street
Camp Hill,PA 17011
Dear Mr.Bangs:
Re: CONTRACT/CERTIFICATE#2637363
This letter is in response to the inquiry recently submitted for the annuity contract referenced above. The date of
death value as of 09/04/2014 was$128,774.89.
If you have any questions or need additional information,please contact our case managers at 1-877-543-2363,
weekdays from 9:00 a.m.to 5:00 p.m.EST.
Sincerely,
John Hancock Annuities
Insurance products are issued by John Hancock life Insurance Company(U.S.A.)(not licensed in New York),Boston,MA 02116;
Registered insurance products are securities and are offered through John Hancock Distributors LLC,197 Clarendon Street,Boston,MA 02116.
t
John Hancock Life Insurance Company(U.S.A.)
John Hancock Annuities Service Center
30 Dan Road,Suite 55444,Canton,MA 02021-2809
Mailing Address:PO Box 55444,Boston,MA 02205-5444
(877)543-2363
www.jhannuities.com
December 18,2014
Michael L.Bangs,Esquire
Bangs Law Office,LLC
429 South 18th Street
Camp Hill,PA 17011
Dear Mr.Bangs:
Re: CONTRACT/CERTIFICATE#FX06007543
This letter is in response to the inquiry recently submitted for the annuity contract referenced above. The date of
death value as of 09/04/2014 was$271,782.34.
If you have any questions or need additional information,please contact our case managers at 1-877-543-2363,
weekdays from 9:00 a.m.to 5:00 p.m.EST.
Sincerely,
John Hancock Annuities
Insurance products are issued by John Hancock Life Insurance Company(U.S.A.)(not licensed in New York),Boston,MA 02116;
Registered insurance products are securities and are offered through John Hancock Distributors LLC,197 Clarendon Street,Boston,MA 02116.
Bangs Law Office, LLC
From: Vincent Gumatay <VincentGumatay@jhancock.com>
Sent: Thursday, December 18, 2014 2:48 PM
To: mikebangs@verizon.net
Subject: Pending John Hancock Claim, Eugene H. Hertz, contract# FX06007543( Non-Qualified)
and 2637363(Qualified)
Attachments: FX06007543.pdf; 2637363.pdf; Non-Qualified National Kit (140102).pdf;Qualified
National Kit (140101).pdf
Good afternoon, Mr. Bangs.
Please see the attached letters per your request as well as the respective claim kits for each contract.
I am the Claims Case manager for these accounts. Please contact me directly if you or the beneficiaries have any
questions at all.
Yours Truly,
Vincent Gumatay I Sr. Case Manager, Death Benefit Administration
PO Box 55445 1 Boston, Massachusetts 02205-5445 1 T. 617 663-2845 Ext. 732845
VincentGumatay0jhancock.com I iohnhancock.com
r-�
We operate as John Hancock In the U.S.and as Manulite in other parts of the world.
Please do not respond to this email address with inquiries, claim paperwork, or other processing requests.
Transaction requests via email will not be accepted. If you require further assistance please contact John
Hancock Annuity Claims at(877) 543-2363 Monday through Friday during the hours of 9:00am to 5:00 pm EST.
Thank you.
The information contained in this email and any attachments is strictly confidential and is for the use of the intended
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any attachments.
1
Van
muwde
P.0, Box 2600
November 25, 2014 Valley Forge, PA 19482-2600
www.vanguard.com
MICHAEL L BANGS
BANGS LAW OFFICE LLC
429 SOUTH 18TH STREET
CAMP HILL PA 17011
Re: Estate of Eugene H. Hertz
Dear Mr. Bangs:
I am responding to the letter we received requesting a valuation of Eugene H.
Hertz's Vanguard account as of September 4, 2014. The information requested is
included on the enclosed account value report.
If you have any questions, please contact me at 855-422-4961, Ext. 61156. 1 will
be pleased to assist you. You can reach me on business days from 9 a.m. to
5:30 p.m., Eastern time.
Sincerely,
Gwendolyn Oliver
Transition Assocoiate
Enclosure(s): **Eugene H. Hertz Individual Account Value Report
52820396
UJKM
Vanguard" Page > 1 of 1
Eugene H Hertz
1401 Barnegat Ave Voyager Services:800-284-7245
Surf City, NJ;8008-6428
Total report value: $80,413.22
(Total report value includes any accrued dividends.)
Name fun &:Accourit - Date f5rice rued--
Nurt ber Opened Shares Share Value'. ptwde�ids
PA LT Tax-Exempt Admiral 0577-88071376455 11/21/2013 6,923.405 $11.61 $80,380.73 $32.49
Totals S$0380 73 : Si2:49.
Doesn't include accrued dividends.
1748814695 11/25/2014 08:19:06
AC KS ON"
NATIONAL LIFE INSURANCE COMPANY
1 Corporate Way
Lansing.Mi 48951
November 5, 2014
Michael L Bangs, Esq
Bangs Law Office, LLC
429 South 181' St
Camp Hill, PA 17011
RE: Policy Number(s) 1006025931
Insured: Eugene H Hertz
Dear Michael L Bangs:
Please extend our condolences to the family on the loss of Eugene H Hertz. We want you to
know that we are available for any questions you may have.
As requested, the date of death value as of September 4, 2014 is $207,539.56.
Attached is a copy of the Variable Annuity Death Benefit Claim form that will need to be
completed by the named beneficiary(s).
Your service needs are very important to us. If you have additional questions or concerns,please
contact our Service Center at 888/565-4995, Monday through Thursday, 8:00 a.m. to 7:00 p.m.
and Friday 8:00 a.m. to 6:00 p.m. (ET). You may also contact Jackson via email through
"Contact Us"on our website at www.jackson.com.
Sincerely,
4UpA-
Laura
Hanson
VP, Policy Owner Services
0
Variable Products issued by Jackson National Life Insurance Companye)and distributed by Jackson National Life Distributors LLC,member NASD,80565-8797
P H Q E N I X PO Box 8027 Phone 800.628.1936
Boston MA 02266-8027 Internet www.PhoenixWM.com
Phoenix Life Insurance Company
PHL Variable Insurance Company
Phoenix Life and Annuity Company
Members of the Phoenix Company lx.
November 7,2014
MICHAEL L BANGS, ESQUIRE
BANGS LAW OFFICE, LLC
429 SOUTH 18TH STREET
CAMP HILL PA 17011
RE: Contract/Policy: 28153979
Deceased: EUGENE H HERTZ
Claim No: 141014DSI I I I
Dear Michael L Bangs,Esquire:
We are sorry to learn of the passing of EUGENE HERTZ and wish to express our sympathies.
Our records indicate that proceeds are payable to Sandra J Mannherz, 34%, Cynthia A Poole, 33%&Susan
M Wagner,33%,children equally.
We need your help in completing the claim process by providing the following:
❑ a certified copy of the death certificate (showing cause&manner of death)
❑ completion and return of the enclosed Beneficiary Statement(s)and Notice(s)of Withholding
❑ return of the policy/contract(s)
The death benefit is$98,625.21. The taxable gain based on the death benefit value is $98625.21. Please
note that the actual death benefit will be calculated based on the date of death and in accordance with the
contract provisions.
The enclosed annuity settlement option grid lists the settlement options available. The beneficiary may
wish to contact a tax adviser to assist in making an informed decision.
Over the years, our beneficiaries have told us that this is a difficult time for making financial decisions. In
response to this concern, the proceeds are placed in our Phoenix Concierge Account. The account earns a
competitive interest rate (currently 1.05%), is fully guaranteed by Phoenix, and provides check-writing
privileges free of charge. The Phoenix Concierge Account allows time for well planned decisions while the
funds continue to grow. For residents of New York, to receive the benefits of the Phoenix Concierge
Account you will need to make an affirmative election by checking a box on the enclosed Beneficiary
Statement. Otherwise,you will receive a single check.
Any tax advice contained in this communication(including any attachments) is not intended to be used,and
cannot be used,to avoid penalties imposed under the U. S. Internal Revenue Code, and was written to
support the promotion or marketing of the transactions or matters addressed here. Individuals should seek
independent tax advice based on their own circumstances.
We are ready to assist you with these important financial matters. Our Claims Examiners are available at
1-800-814-3692 to answer your questions Monday through Friday from 8:30 a.m. to 5:00 p.m.Eastern
time. As always,we appreciate the opportunity to serve your insurance needs.
CORNERSTONE
P.O. Box 1181, 5 Eastgate Drive, Carlisle, PA 17015
F e d e r a l C r e d i t U n i o n Telephone (717) 249-1661 FAX (717) 249-8208
Member founded— Service based www.cornerstonefcu.coop
November 7, 2014
Bangs Law Office, LLC
429 South 18th Street
Camp Hill PA 17011
Re:The Estate of Eugene H. Hertz
Dear Michael:
At the time of his death, Eugene H. Hertz had two single accounts with POA Alan and Sandra Mannherz
Listed below is the information you requested in your letter dated October 16, 2014.
1.) Account number and type of accounts
12247-01 Savings 07 Checking
82247-01 Savings 18 Money market
2.) Account was opened
12247-Savings &Checking 1/15/1982
82247-Savings & Money Market 11/5/2002
3.) Balance as of September 4,2014
12247-0 1 $127.50
12247-07-07 $25,047.80
82247-01 $49831.27
82247-18$21,965.48
4.) Interest not posted
12247-01 $ .04
12247-07 $.06
82247-01 $ 12.29
82247-18 $ .48
If you require any further information, please call me 717-249-1661 ext 251
Sincerely:
/n• _ r .
• i 1
Cindy Willhide
Financial Service Representative
MEMBER SAVINGS ACCOUNTS FEDERALLY INSURED TO $250,000 BY THE NATIONAL CREDIT UNION ADMINISTRATION
MEMBERS 1u
FEDERAL CREDIT UNION
REGULAR SAVINGS ACCOUNT:
*ccnurtmumbemjuffim 145541'00
Date Account Established 08/19/1994
Principal Balance ot Date ofDeath $711.99
Accrued Interest to Date of Death $0.01
Total Principal and Accrued Interest 8712.00
Name ofJoint Owner None
INVESTMENT SAVINGS ACCOUNT:
f\ccountNumUer/buff|x 145541'05
Date Account Established 08/26/1094
Principal Balance atDate ofDeath $19.48156
Accrued Interest to Ueto of Death $0.16
Total Principal and Accrued Interest $19.491.72
Name VfJoint Owner None
MEK4BERS 1 or FEDERAL CREDIT UNION
T Zes�s�alL K I u g�h
Lending Insurance Support Specialist
December 31. 2O14
'
Estate of: EUGENE H HERTZ
Date mfDeath: 09804/2014
Social Security Number:
500OLouise Drive ° I!(}. Box 40 , }1ec6uoics6ozg, Peoos!1rxuix 17055 ° (80() 283'2328 ° n,n`sroccnberslscozg
THE LAW OFFICE
of:
JAMES M. BACH
Attorney-At-Law
352 S. Sporting Hill Road
Mechanicsburg, PA 17050
737-2033
LAST WILL AND TESTAMENT
FOR
EUGENE . HERTZ
Last Will And Testament Of
EUGENE H. HERTZ
I, EUGENE H. HERTZ, of the BOROUGH OF MECHANICSBURG, COUNTY OF
CUMBERLAND,COMMONWEALTH of PENNSYLVANIA,being in good bodily health and of
sound and disposing mind and memory, and not acting under duress, menace, fraud, or undue
influence of any person whomsoever, merely calling to mind the frailty of human life, and being
desirous of disposing my worldly goods while I have the strength and capacity so to do, I do make,
publish and declare this my LAST WILL AND TESTAMENT. I hereby revoke, cancel and
annul all my former Wills and Testaments,including codicils thereto,by me at any time made,and
declare this alone to be my LAST WILL AND TESTAMENT.
AS TO SUCH ESTATE IT HAS PLEASED GOD TO ENTRUST ME WITH IN THIS
LIFETIME,I DISPOSE OF THE SAME AS FOLLOWS,VIZ:
ITEM 1. I direct that my Co-Executrixes hereinafter named,pay and discharge all of my just
debts,funeral and testamentary expenses.
ITEM 2. I order and direct that I be buried in a lot,which I own situate at the Resurrection
Cemetery,Harrisburg,PA.
ITEM 3. I give, devise, and bequeath any automobile that I own at the time of my death to
Cynthia A.Poole,per stirpes.
ITEM 4. I give,devise, and bequeath my interest in my dwelling house and contents known
and numbered as 907 E. Coover Street,Mechanicsburg,PA to Gloria J. Hertz,per
stirpes.
ITEM 5. I give,devise,and bequeath the balance and contents of my checking account at the
Cornerstone Federal Credit.Union or any other financial institution-to Gloria J.
Hertz,per stirpes.
ITEM 6. All the rest, residue and remainder of my entire estate, wheresoever situate, and
whatsoever it may consist of, I give,devise and bequeath,absolutely, and in fee,to
my dearly beloved children, share and share alike, per stirpes. My children are
named as follows:
1. Sandra J.Mannberz
2. Cynthia A.Poole
3. Susan M.Wagner
UGENE H.'HERTZ
1
ITEM 7. I nominate and appoint,Sandra J.Mannhen,Cynthia A.Poole and Susan M.
Wagner,as Co-Executrixes of this my Last Will and Testament. .
I'T'EM 8. I hereby direct that all my personal representatives,as well as their successors, shall
not be required to give bond for the faithful performance of their duties in any
jurisdiction.
ITEM 9. I order and direct that my Personal Representative(s) named herein use the legal
services of James M. Bach,as Attorney for my Estate.
i
jITEM 10. I direct that all estate,succession,legacy,inheritance or other transfer taxes,however
designated that shall become payable by reason of my death in respect of all property
comprising my gross estate for tax purposes, whether or not such property passes
under this LAST WILL, shall be paid by my Co-Executrixes out of my residuary
estate.
ITEM 11. 1 grant to my personal representatives herein named, in addition to, but not in
i
limitation of those powers vested by law,to be exercised without prior application to
or approval of any court,the power and authority to retain indefinitely any property,
to invest and reinvest any assets or the proceeds derived from the sale of assets,
although said investments may not be of the character prescribed by law, to sell,
convey,assign, transfer and encumber any property,to pay,settle or compromise all
claims,to make distribution or divisions in cash or in kind,and in general to exercise
I
all powers in the management of any property hereunder which any individual could
exercise in the management of similar property owned in his own right, and to
execute and deliver any and all instruments and to do all acts,which may be deemed
necessary and proper.
! UGENE H.HERTZ
i
i
r
i
z
ACKNOWLEDGMENT
COMMONWEALTH OF PENNSYLVANIA )
ss
COUNTY OF CUMBERLAND )
I,EUGENE H HERTZ,the TESTATOR,whose name is signed to the attached or foregoing
instrument,having been duly qualified according to law,do hereby acknowledge that I signed and executed
the instrument as my LAST WILL;that I signed it willingly;and that I signed it as my free and voluntary act
for the purpose therein expressed.
i
Sworn to or affirmed and acknowledged before me,by: the TESTATOR this 6th day of November 2Q92.
EUGENE H.HER
JAAM—MCK H-kwr•rte J S M.BACH,ESQUIRE
Ho Pow Twp.,CW"iokr+d commy ARY PUBLIC
CO^'MMWI AUr,is IpOtt echanicsburg,PA 17050
My Commission Expires: 05/13/03
The preceding instrument consisting of this and two(2)other typewritten pages,identified by the
signature of the TESTATOR,was on the date thereof signed,published and declared by EUGENE H.
HERTZ the TESTATOR therein named as and for his LAST WILL AND TESTAMENT.
Residing at 352 S.Sporting Hill Road
FATIMA A.SKI/MIND rMlechaaicsbMM PA 17454
Residing at 3525,SFgoing Hill Road
TERESA H.LAUGHEAD M–ccha{icsbu_P.PA 17050
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA)
ss
COUNTY OF CUMBERLAND }
We, FATIMA A. SKIM-IN and TERESA H LAUGHEAD the witnesses whose names are
signed to the attached or foregoing instrument,being duly qualified according to law,do depose and say that
we were present and saw the TESTATOR sign and execute the instrument as his LAST WILL; that the
TESTATOR signed it willingly and that he executedit as his free and voluntary act for the purpose therein
expressed;that each witness in the hearing and sight of the TESTATOR.signed the WILL as witnesses;and
that, to the best of our knowledge, the TESTATOR was,at the time, 18 or more years of age,of sound
mind and under no constraint or undue influence.
Sworn to or affirmed and acknowledged before me by FATIMA A SKIMIN and TERESA H.
LAUGHEAD,witnesses,this-6th-day of November2002.2
FA .S TERESA H.LAUG
1A.
W
3AIAE5 41C?tCK,tMR+ry ttilric
E*
T"p jchaniy..burg,
M.BACH,ESQUIRE
NN coo"M�+�►Wr 1%� RPUBLIC
PA 17050
mmission Expires: 05/13/03
1
3
CODICIL TO THE LAST WILL AND TESTAMENT
OF EUGENE H. HERTZ
1, Eugene H. Hertz, an adult resident of the County of Cumberland, State of Pennsylvania, located
at 907 E. Coover Street, Mechanicsburg, PA, 17055, being of sound mind, declare this Codicil to
my last Will and Testament (which was executed by me on November 6, 2002) to be immediately
effective as of the date of my witnessed signature below.
Whereas, I no longer own any automobile or any other vehicle.
Whereas,lGloria J. Hertz has predeceased me on March 3, 2013.
Whereas, I wish to bequeath my entire estate with all my worldly belongings (material, financial,
or otherwise) to my biological children as named in my Will (see ITEM 6).
Whereas,I now believe my appointed Co-Executrixes should be able to decide for themselves
which legal counselor or lawyer is needed for them to properly execute my Will.
I add or Oanp_e said Will in the following manner:
I delete from said Will "ITEM 3" in its entirety.
I delete from said Will "ITEM 4" in its entirety.
I delete from said Will "ITEM 5" in its entirety.
I delete from said Will "ITEM 9" in its entirety.
Otherwise, I hereby confirm and republish my Will, dated November 6, 2002, in all respects other
than those herein mentioned.
I subscribe this my Codicil to Will on this day of f <I-
Signature
Eugene H. Hertz
Page 1 of 2
CODICIL TO THE LAST WILL AND TESTAMENT
OF EUGENE H. HERTZ
We, the undersigned, do hereby certify that the above instrument, which consists of two (2)pages,
including the page which contains the witnesses signatures, was signed in our sight and presence
by Eugene' H. Hertz(the Testator) who declared this instrument to be the First Codicil to his Last
Will and Testament and we, at the Testators request and in his sight and presence, and in the sight
and presence of each other, do hereby subscribe our names as witnesses on the date shown above.
Witness One Signature: Ab
I
Witness One Name: (print) 615e erre
Address: qbb Cpyvef- ,S�,
IA4�4 All
Witness Two Signature:-,-
Witness Two Name: (print IOU
Address: ?'04? Z7,
Page 2 of 2