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Home My WebLink About01-0291 - PETITION FOR PROBATE AND GRANT OF LETTERS Estate of: ERMA M. HARTZ No. 21-01-291 Also known as: To: Register of Wills for the Deceased County of Cumberland in the Social Security Number: 1159-18-1092 Commonwealth of Pennsylvania The Petition of the undersigned respectfully represent that: 1. Your petitioner( s), who is/are 18 years or older and the executrix named in the last will of the above decedent, dated August 6, 1997. IN/A (State relevant circumstances, e.g. renunciation, death of executor, etc.) 2. Decedent at death was domiciled in Cumberland County, Pennsylvania, with hislher last family or principal address at: Street address City Municipality State Zip code 100 Mt. Allen Drive Mechanicsburg Upper Allen PA 17055 3. Decedent, then 83 years of age, died on February 27,2001 4. Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the will offered for probate; was not a victim of a killing; and, was never adjudicated incompetent: I N/A 5. Decedent at death owned property with estimated values as follows: (If domiciled in PA) All personal property $42,000.00 (Ifnot domiciled in PA) Personal Property in Pennsylvania (If not domiciled in P A) Personal property in County Value of real estate in Pennsylvania $0.00 situated as follows: N/ A WHEREFORE, petitioner(s) respectfully request(s) the probate and codicils(s) presented herein and the grant of letters: I Testamentary (Testamentary, administration c.t.a.; administration d.b.n.c.t.a.) thereon. signatures and residences of petitioner( s) Shirley A artz 9 Wayside Court Dillsburg, PAl 70 19 /6- ,..;2./?- /~ . '~ ~" OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND : SS : SS The Petitioner(s) above named swear(s) or affrrm(s) that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of the petitioner (s) and that as personal representative(s) of the above decedent, petitioner(s) will well and truly administer the estate according to law. Sworn to or affirmed and subscribed before me ~is ~day of MARCH _. ,2001. ~;:[' a'7;/b~~U~c-€(j nyPu J'j/ .-. ""- No. 21-01-291 Estate of ERMA M HARTZ , Deceased DECREE FOR PROBATE AND GRANT OF LETTERS AND NOW, MARCH 16 ,2001, in consideration ofthe petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument dated August 6, 1997 described therein be admitted to probate and filed of record as the last will of Erma M. Hartz and Letters Testamentary are hereby granted to Shirley A. Hartz.. ~/' r1,';f;""?//'/<':; /D~ ," egister of Wills ",:" . ~_...... . ... . . FEES Short Certificate(s) Probate, Letters, etc. Renunciation( s) Miscellaneous JCP TOTAL Filed 3-14-01 $ $ $ x-pages $ $ 80.00 6.00 21.00 5.00 11< 00 ............................. DIANE G. RADCLIFF, ESQUIRE Supreme Court J.D. # 32112 3448 Trindle Road, Camp Hill, P A 17011 Phone: (717) 737-0100 Fax: (717) 975-0697 I 'rYJ~) ~ ~~/~ ~'i;S ;S ro cerrj,cv rJlat tile information here given is correctly copied from an original cerrificate of death dl,fly filed with me as L(I(al.f~q~istr~1I" The original certificate will be forwarded to the State Vital Records Office for permanenr filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certitlcate, $2.00 No. I! fAA-V"","',,.;. k.Jv" .Lf1 Local Registrar p 7234123 17{~ " ~()O L Date 21-01-291 Hl05.143Aev.2/87 TYPfJPAINT III PERMANENT 8LACKINIC. ~? COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH NAME OF DECEDENT (fir... Middle, La.) Female STATE FlU: NUMBER SOCIAL SECURiTY NUMBeR ,. AGE (l. BirlMay) UHOEA 1 YEAR - Iloyo Erma M. Hartz UNDER 1 OAr Hour. j MinuIM sex 83 v... COUNTY OF DeRH BIRTHPlACE (City and Stale 01 Fore.gn COtJOIl'y) .. 159 18 - Cumberland DEClODENT'S USUAl OCCUl'RlON (~~~of~:O~:::3,~ 11.. Custodian ".. DECEDENT'S MAIlING AOORess (SIr.... CityflOwn, Stat., ZOlpCode) Ie. 178. Sa.. Did - /twine Cumberland -' "..0 ::"'''':::':..'":'.. MOTHER'S NAME (flfst MIddle. MCl108n Surname) MAfUTAt. swus...."., ~ Married. WIdowed, -15_ Widowed "c.lil ...,_...... tipper Allen ID. While II. AQ'HER'S NAUE {Fitsl. M~, last) 100 Ml. Allen Drive Mechanicsburg, Pa. 17055 DECEDENT'S CTUAL RESIDENCE (Seelnsr,UCIlClnS 00 Olher SIde) ". SURVIVING SPOuSE Il!wH.gA>etrloiillOent'lM'lel .... ".. o w '" :> ~ < Lewis Bentz Shirley A. Hartz Cltylbofo Mar 2, 2001 21.. Carlisle, Pa. 17013 ltCENSE NUMBER 21c. 22b. .. belt of tnv know.... de.'" occurred _the 111M, date and pblce ..aled (SlgnaIlJre and TiUe) FD-012755-L Inc. 37 East Main Street Mechanicsbur , Pa 17055 ORE SIGNED (Monln. Day. __ill' "'9 CASE REFERRED TO MEDfCAl EXAMINE ...0 R? H. I AppJoam.re '-- : 0RMt and dNIh , I ...-:! MAT I: 0Itw ~ cotMMione,canIIibuIina IO~. bIIt noe: r.....an 1M ~ C*'Mgrven In PART I ~ f: .; L i'l II I WERE AUTOPSy FINOtNQS ~l..A8lE PtUOfi 10 COMPlETION OF CAUSE OFOEATH? MANNER OF DEATH NaIU'" I5l. o o DATe OF INJURY lMonIfl, Day, 'feat) TIME OF INJUfly INJURY A7 WORK? DESCRIBE HOW INJURY OCCURRED. Homicide o o o PlACe OF INJURY .Alhome.larm, _reel. factor'y.oflIce M. budding, Me. lSpacd,,1 .... ... 0 NoD Ace...... Pending IflVe$ligalion ...0 NoD """.... Cot.tkj not be oJel.rmlned a.. 21b. CSlTlflER ICheck only onel 'CERTIFYING PHYSICIAN (Ph'f'SlCISfl cetblYII\Q cause 01 deam wheo .1notner p/1",~I(:'an h.;ts prOrlOl.Jncea .ledlh d.fIQ COfl1pIL'Ie<1 n~o 2:.31 TOhta...o'....Yknow~...thClCCurr..,dU41to"'-cau....)andm.nner.....ted.. ................................. .MEDICAl EXAMJtf.ERlCQAONER On the b..le of ..aminatlon and/Of Inv..tigation. in my opinion. death OCcurred allhe time, da'e, and plo.ce. and due to the cau..(aj and mann.,. aa "eted.. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .........,..............................................,......... 31, REGIS~ 'S SIGNATURE AND NUMBER o o 2.. 1..:4 'I~ I II.) I ,Pa.17110 ~ ~ fiJ iil o 1; ~ :> ~ z 'PRONOuNCIHQ AND CEATtFYIHG PHYSK:JAN (Ph'f'$lCI;IO bolh ;JfOf\O\.j!lClog lJedlh <.IlId Certlty'"9 JO o..;"ll:a! lOll 06dlh) To the~. of my knowledge. de.1h OCCUfr.d.. lha Um.~ cUI..;.nd pI.c., and due to.tt. ceu..(.).nd m.no., It. .~'ed.. :N. du I 21-01-291 lliast IIill ann m~ghtm.ettt of ERMA M. BARTZ BE IT REMEMBERED, that I, ERMA M. BARTZ, of 9 Wayside Court, Dillsburg, Pennsylvania, Pennsylvania, being of sound mind, memory and understanding, do make, publish and declare this as and for my Last Will and Testament, hereby revoking and making null and void any and all Wills and Testaments and writings in the nature thereof by me, at anytime heretofore made. ITDI 1: I direct that all my just debts and funeral expenses be paid as soon after my demise as may be convenient. It'D 2: I give and bequeath all tangible personal property owned by me at my death and all insurance policies on such property as follows: &. To those individuals who survive me by thirty (30) days who are designated on a list or memorandum signed by me which refers to this Will or is found with a copy thereof, I give and bequeath the items listed beside their names. b. The balance ( inc 1 uding any i terns under subparagraph (a) above the bequest of which has lapsed) shall be included in my residuary estate, and shall be distributed by my hereafter named Personal Representative to the beneficiaries thereof as herein provided. My Personal Representative shall have the right to dispose of the remaining items of personalty that are to become ~ &l/~7r~ '1'Jj ~ ERMA M. BARTZ . (SEAL) 1 part of my residuary estate, either in kind or in cash as a result of liquidation thereof, as my Personal Representative, in her sole discretion, deems appropriate under the circumstances. It is my intent, however, that should any beneficiary of my residuary estate desire to receive a particular item in kind which was not specifically bequeathed to that beneficiary, to the extent reasonably possible, my Personal Representative shall attempt, but not be obligated, to follow that beneficiary's request. c. If any beneficiary of any item of tangible personal property aforesaid has not yet attained the age of 18 at the time of my death, I order and direct that my Personal Representative to hold the items in safekeeping for that beneficiary and to deliver the same to that beneficiary when that beneficiary reaches age 18. For said purposes my Personal Representative shall be entitled to use or set aside from my estate sufficient funds to provide for said safekeeping. I1'DI 3: All the rest, residue and remainder of my Estate, of whatsoever nature and wheresoever situate, whether it be real, personal or mixed, including any insurance policies therefor, property over which I have power of appointment, and proceeds from any insurance policies payable to my estate, I give, devise and bequeath to .BIRLEY A. BARTZ, provided SHIRLEY A. BARTZ survives me by a period of at least 30 days. t~ hJ H-a~ ERMA M. BARTZ (SEAL) 2 ITEM ~: In the event SHIRLEY A. BARTZ, should fail to survive me by a period of at least 30 days SHIRLEY A. BARTl'. share of my residuary estate shall lapse, and in which event I give, devise and bequeath my entire residuary estate to CALVARY UIIITED METHODIST CHURCH OF Dillsburg, Pennsylvania. ITa 5: The share of my estate that shall be distributed to the CALVARY UNITED METHODIST CHURCH of Dillsburg, Pennsylvania pursuant to the terms of Item 4 herein, shall be held by my Trustee, hereafter appointed, I. ..PARATE TRUST, under and subject to the following terms and conditions: a. Trustee shall pay all of the net income of the trust to the beneficiary as often as my Trustee may deem advisable, but at least quarter-annually. b. Trustee shall pay to the beneficiary from the principal of the Trust on an annual basis on or before December 31 of each year the sum of $10,000.00. c. Trustee shall pay to the beneficiary outright any balance remaining in the Trust on the date following 20 years after my death or any date a payment is due pursuant to the terms of the preceding subparagraph when the trust balance is equal to or lesser than $10,000.00. Upon that payment the Trust shall terminate. d. The Trustee for the purposes of carrying out my intentions stated above shall have the following powers, in addition to all other powers granted by law or other provisions of this Will: 1. To retain any property, real or personal, and to manage the same for the benefit of this Trust; 2. To sell at public or private sale, or to lease for any period of time, any real or personal property for such prices and upon ( ~~_?fj ~ ERMA M. BARTZ. (SEAL) 3 such terms and conditions as may be appropriate; 3. To compromise any claim or controversy and to abandon any property which is of inconsequential value; t. To make distribution to my herein-named beneficiaries, on their behalf, in cash or in kind; and 5. To carryon any business owned or controlled by me at my death, for whatever period of time is deemed proper, and to do all things necessary and appropriate to manage, supervise and operate the business and to close out, liquidate or sell the business at such time and upon such terms as are deemed proper. c. Trustee shall invest all trust funds received by my Trustee including, but not limited to, income received from the retention of property in kind and cash received from the liquidation and sale of property, in any minimal risk investment including, but not limited to, savings accounts, money market accounts, certificates of deposit or other minimal risk investments, or any combination thereof. Distribution from the Trust shall be made solely for the benefit of the beneficiary of the Trust in accordance with my instructions set forth in subparagraph (a); provided, however, that my Trustee shall be entitled to pay for any taxes, professional services or other fees arising out of the administration of the Trust and shall be entitled to periodic, reasonable compensation for services rendered hereunder, which may be equitably apportioned between principal and income. d. Any and all payment or payments of any sum or sums, whether in cash or in kind or whether for principal or income, payable to the beneficiary, shall be made upon the sole receipt of the respective individual to whom the payment is made, free from anticipation, alienation, assignment, attachment, and pledge, free from control by the creditors of any such beneficiary and shall not be subject to any execution or attachment. e. Should the principal of the Trust herein provided for be or become too small in the Trustee's discretion so as to make establishment or continuance of the trust inadvisable, my Trustee or Personal Representative may make immediate distribution of the then-remaining principal and any accumulated or undistributed income outright to ( (;-V'~~. /'H /"~fr;V2.>5 ERMA M. BARTZ (SEAL) 4 the person or persons and in the proportions they are entitled. I!'D 6: I appoint PRe BARK as Trustee of any Trust created by this my Last Will and Testament. ITDf 7: I appoint SHIRLEY A. BARTZ as my Personal Representative of this my Last Will and Testament, and direct that my Personal Representative shall administer my estate and make the distributions herein provided. Should ..IRLBY A. BARTZ, predecease me, fail to qualify, cease to act or renounce probate, I then appoint DIARE G. RADCLIPP, _SQUIRE, as the Alternate Personal Representative of this my Last Will and Testament. ITDf 8: I direct my Personal Representative to pay all inheritance, estate, succession and legacy taxes of whatsoever nature and kind, to which my Estate or any person receiving the transfer of any property passing hereunder or otherwise passing by reason of my demise, may be subject and to charge such taxes against my residuary estate, it being my intention that none of the aforesaid taxes, either federal or state, or any property required to be included in my gross estate, under the provisions of any state or federal law now in force or hereafter enacted, shall be prorated among the persons interested in my Estate to whom such property is or may be transferred or to whom any benefit accrues. ITEM 9: In addition to the powers conferred by law, I authorize my Personal Representative in her absolute discretion: ~_ In ~ ERMA M. BARTZ (SEAL) 5 .. To retain in the form received, and to sell either at public or private sale any real or personal property; b. To manage real estate; c. To invest and reinvest in all forms of property without being confined to legal investments, and without regard to the principle of diversification; d. To exercise any option or rights arising from ownership of investments; e. To compromise claims without court approval and without the consent of any beneficiary; f. To disclaim any interest in property; g. To claim an elective share of the estate of any deceased spouse; h. To join with any spouse I may have upon my death in the filing of any federal income tax return for any year for which I have not filed such return prior to my death, and to consent to the treatment of any gifts made by my spouse as being made one-half by me for gift tax purposes notwithstanding the fact that such action may result in additional liabilities for my estate. Any income or gift taxes due on such returns and any deficiencies, interest, penalties, or refunds thereon, shall be allocated between my estate and my spouse and my spouse's estate, or all to any of them, in such manner as my Personal Representative and my said spouse may agree. l C~?n~ ERMA M. BARTZ r (SEAL) 6 i. To disburse my estate in kind or by way of liquidation thereof, in whole or in part, as my Personal Representative in her sole discretion may deem appropriate under the circumstances. ITEM 10: I direct that my Personal Representative or her successors shall not be required to give bond for the faithful performance of her duties in any jurisdiction. I. WITRBSS WHBREOF, I have hereunto set my hand and seal this fJ!... day of 01 {j"i'JL ,19 C/'7 I ~ h1 /I-.v1 ( SEAL) \ BRMA M. BARTZ 7 ACKBOWLEDGMERT COMMONWEALTH OF PENNSYLVANIA SSe COUNTY OF CUMBERLAND We, BRMA M. HARTZ, Diane G. Radcliff and Kelly S. Quinn, the TBSTATRIX and the witnesses respectively, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the TESTATRIX signed and executed the instrument as the TESTATRIX's Last Will and that TESTATRIX had signed willingly (or willingly directed another to sign for ), and that TESTATRIX executed it as TESTATRIX free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the T.STATRIX, signed the Will as witnesses 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. ~zu~ ~- ERMA M. BARTZ ( '-.. Sworn to and subscribed to before me this 6 C!h day of CfuaLWt ,1992-. ~JpuC~ My Commission Expires: NOTARIAL SEAL J?08fN-<Z,;CAMPSEll, Notary PUbllc camp Hill Boro, Cumberland County .'yCOmmission Expires Jury 3, 1999 8 DIANE G. RADCLIFF, ESQUIRE Attorney at Law 3448 Trindle Road Camp Hill, Pennsylvania 17011 Phone: (717) 737-0100 Facsimile: (717) 975-0697 May 23, 2001 Cumberland County Register of Wills Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013 Re: Estate of Erma M. Hartz No. 2001-00291 Dear Sir/Madam: Enclosed herewith please find ~ check payable to the Register of wills - Agent in the amount of $2,257.00 as prepayment of the Inheritance Tax on the above referenced estate. Very truly yours, DGR/dd Enclosure: Check I cc: Shirley A. Hartz t 'tt'tt'tt'f(iC'tt'tt'ICil ~.J!"~n ....J- c a:::1~ ~-........ en ~c~~ O'l -::oi =: ..... -- ~ - :l:c:t: i'rl a:: 0... Q U ~ i'rlOI ~~~ Q co . i'rl ~~ N d.~ i .il~ , > ( ~ '5 C" ." """" I!' """" ~"O 0 :=CO"- = 0 """" .gn::<( CO ,,) D- o: ~ ._- (!) 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HARTZ DATE OF DEATH: February 27, 2001 WILL NO. : 21-2001-0291 ADMIN. NO. : TO THE REGISTER: I certify that Notice of Estate Administration required by Rule 5.6(a} of the Orphan's Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on : NAME AND ADDRESS STATUS 1. Shirley A. Hartz 9 Wayside Court Dillsburg, PA 17019 Daughter Notice has now been given to all persons entitled thereto under Rule 5.6(a} except: NAME ADDRESS None N/A Date: 6/20/01 Signature: Name: Address: 'ff, e Road C A 17011 (717) ,737-0100 32112 Counsel for Personal.: Repre~aentative Telephone: I . D. No.: Capacity: \. /6-cJ/7-/.:L- COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE *' BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. Z80601 HARRISBURG, PA 171Z8-0601 NOTICE OF INHERITANCE TAX APPRAISE"ENT. AllOWANCE OR DISAllOWANCE OF DEDUCTIONS AND ASSESS"ENT OF TAX REV-15~7 EX AF' 112-001 RecoroedC[flcc of Register of \/Vills DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 11-26-2oo1 HARTZ 02-27-2001 21 01-0291 CUMBERLAND 101 ERMA M DIANE G RADCLIFF 3448 TRINDLE RD CAMP HILL '01 NOV 30 P 3 :20 ESQ Pgfi~rland co~.op~ Allount Rellitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE. PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REv=is4j-Ex-iFP-n"2-:ooY-NcificE"-oF-YNHEifiTANci-TAi-APPRA-isEiiiNy-,--iLl-owANci-oi----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF HARTZ ERMA M FILE NO. 21 01-0291 ACN 101 DATE 11-26-2oo1 TAX RETURN WAS: (X) ACCEPTED AS FILED CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Stock/Partnership Interest (Schedule C) 4. "ortgages/Notes Receivable (Schedule D) 5. Cash/Bank Deposits/"isc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets (1) (2) (3) (4) (5) (6) (7) .00 .00 .00 .00 .00 7.084.00 37.516.00 (8) NOTE: To insure proper credit to your account. subllit the upper portion of this forll with your tax paYllent. 44.600.00 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adll. Costs/"isc. Expenses (Schedule H) 10. Debts/"ortgage liabilities/liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governllental Bequests; Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax (9) UO) 2.457.00 4.308.00 (11) (12) (13) (4) 6.761i 00 37.835.00 .00 37.835.00 NOTE: I~ an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will re~lect ~igures that include the total o~ ALL returns assessed to date. ASSESSMENT OF TAX: 15. Allount of line 14 at Spousal rate (15) 16. Allount of line 14 taxable at lineal/Class A rate (16) 17. Allount of line 14 at Sibling rate (17) 18. Allount of line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due TA CElTS: PAY" T DATE 05-23-2001 .00 X 37.835.00 X .00 X .00 X 00 = 045 = 12 = 15 = (9)= .00 1.703.00 .00 .00 1.703.00 REC IP NU"BER AA496643 D SCO T (+) INTEREST/PEN PAID (-) 85.15 A"OUNT PAID 2.257.00 TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE 2.342.15 639.15CR .00 639.15CR . IF PAID AFTER DATE INDICATED. SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS lESS THAN $1. NO PAY"ENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR). YOU "AY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FOR" FOR INSTRUCTIONS.) t- <-/..... STATUS REPORT UNDER RULE 6.12 NAME OF DECEDENT: ERMA M. HARTZ DATE OF DEATH: February 27, 2001 WILL NO.: 21 01-0291 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 No x b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes x No d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. lot / f F RE Name (please type or print) Date: \'2- /,' I '0 f"") ':'t 3448 Trindle Road. Camp Hill. P A 17011 Address ':,1) (.:' - d: (717) 737-0100 Telephone number N "'i.e",. 'to.,,' ~~::::~ .t~: 6 "t:.ry Q (1) ~a: c..J CJ ,,'0 ",""". (i.) , .D CS:: a>= UU Capacity: _ Personal Representative p -X- Counsel for personal representative COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG. PA 17128-0601 ......................OFFi(;"IAL.i.iSE:"ONi:Y......................~ E :- REV -1500 INHERITANCE TAX RETURN RESIDENT DECEDENT I- Z w Cl w c..l w Cl ! t5~~ .0.8 02- 1::"' <( 5. Federal Estate Tax Return Required ~ i C> <..> 1. Real Estate (Schedule A) (1) $0.00 $0.00 $0.00 $0.00 $0.00 $7,084.00 $37,516.00 (8) $2,457.00 $4,308.00 (11) (12) (13) (14) (15) (16) (17) (18) (19) OFFICIAL USE ONLY 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) z o ~ :::> l- ll. <( U W a:: 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Misc. Personal Property (Schedule E) (4) (5) (6) 6. JoinUy Owned Property (Schedule F) . Separate Billing Requested 7. Inter-Vivos Transfers & Misc. Non-Probate Property (Schedule G or L) (7) 8. Total Gross Assets (total Lines 1-7) $44,600.00 9. Funeral Expenses & Administrative Costs (Schedule H) 10. Debts of Decedent, Mortgage Liabilities & Liens (Schedule I) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 13. Charitable and Governmental Bequests/See 9113 Trusts for which an electlon to tax has not been made (Schedule J) (9) (10) $6 765 00 $37,835.00 SO.OO $37,835.00 z o ;: ~~ >-OJ .. ~ o () 14. Net Value Subject to Tax (Line 12 minus Line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (8)(1.2) $0.00 x I x x .12 x .15 16. Amount of line 14 taxable at lineal rate $1,703.00 $0.00 17. Amount of line 14 taxable at sibling rate 18. Amount of line 14 taxable at collateral rate 19. Tax Due $000 $1,703.00 20.. CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT I~-;(Jf}-/~ Copyright 2000 David James Thorpe, Esq. Decedent's Complete Address: STREET ADDRESS - TotallnterestlPenalty (0 + E) 'fllne 215 greater than line 1 + line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund (4) If line 1 + Una 3 is greater than fine 2, enter the difference. This Is the TAX DUE. (5) A. Enterthe;ntereston the tax due. (5A) ~l."! B. Enter the total of line 5 + 5A. This is the BALANCE DUE. (58) Make Check Payable to: REGISTER OF WILLS, AGENT Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C) 3. Interest/Penalty If applicable D.lnterest E. Penalty 4. 5. (1) $1,703.00 (2) $2,370.00 (3) $0.00 $667.00 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN X IN THE APPROPRIATE BLOCKS 1. 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 revisionary Interest; or d. receive the promise for life of either payments, benefits or care? 2. If death occurred on or before December 12, 1982, did decedent within two years preceding death transfer property without receiving adequate consideration? If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? 3. Old 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? Yes I No I . I IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties of perjury, I declare that I have examined this retum, Indudlng accompanying schedules and slalements, and to the best of my knowledge and belief, It Is true, correct, and complete. Declaration of preparer other than the personal representalive is based on all the information of which preparer has any knowledge. Copyright 2000 David James Thorpe, Esq. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF ERMA M. HARTZ FILE NUMBER 21-01-0291 TOTAL (Also enter on line 7. Recapitulation) (If more space is needed, insert additional sheets of the same size) Copyright 2000 David James Thorpe, Esq. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTL y-oWNED PROPERTY ESTATE OF ERMA M. HARTZ FILE NUMBER 21-01-0291 if an asset was made joint within one year of the decedent's date of death. It must be reported on Schedule G. JOINTLy-oWNED PROPERTY: DESCRIPTION OF PROPERTY DATE OF DEATH Indude name of financial institution and bank account number or similar Identifying number. AttaCh VALUE OF ASSET deed for jolnlly.neld real estate. ' TOTAL (Also enter on line 6. Recapitulation) (If more space is needed, insert additional sheets of the same size) Copyright 2000 David James Thorpe, Esq. COMMONWEAlTH OF PENNSYLVANIA INHERITANce TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF ERMA M. HARTZ FILE NUMBER 21-01-0291 Debts of decedent must be reported on Schedule I. DESCRIPTION AMOUNT TOTAL (Also enter on line 9, Recapitulation) (If more space is needed. insert additior:al sheets of the same si;ze) Copyright 2000 David James Thorpe, Esq. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF ERMA M. HARTZ FILE NUMBER 21-01-0291 Include unrelmbursed medical expen.... ITEM NUMBER DESCRIPTION AMOUNT TOTAL (Also enter on line 10, Recapitulation) (If more space Is needed, insert additional sheets of the same size) Copyright 2000 David James Thorpe, Esq. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF 21.{)1-0291 AMOUNT OR SHARE OF ESTATE NUMBER I. ERMA M. HARTZ NAME ANO ADDRESS OF PERSON(S) RECEIVING PROPERTY FILE NUMBER RELATIONSHIP TO OECEOENT Do Not List Trustee(s} TAXABLE DISTRIBUTIONS (include outright spousal distributions) TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DiSTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET (If more space is needed, insert additional sheets of the same size) Copyright 2000 David James Thorpe, Esq. ~ '-'e. I" '-- 1-11 'I ... '- ;C Bank Primary account number: 51-4019-6271 Page 1 of 2 For the period 01/26/2001 to 02/22/2001 Number of enclosures: 2 ERMA M HARTZ SHIRLEY A HARTZ 9 WAYSIDE CT DILLSBURG PA 17019-1315 tt For 24.hour cllstomer service or current rates: Call1-S8S-PNC-BANK ~ Write to: Customer Service PO Box 609 Pittsburgh PA 15230-9738 a Visit LIS at www.pncbank.com II TDDterminal: '-800-531-1648 For heflfing imp:lired clients on1r ke a l1.lIite Out or laxes--Consult a FrllC Stukei-age CGi"p restment Consultant Today. a free, un obligalion COllSllllaliOlI. PNC Brokerage Corp offers a wide r~lI1gc of non.hank inVl\SU1wnt products and selTiccs, :1 ,-IS llol\.FDIC insured stocks, hCJllCb;, 1l111lual fuuds, ulIir investment trusts, and other produCls which may h<..~ abl~ to h('lp you ease your income, reduce laxes, pn~pare for college. or plan for retirement. PNC Brokerage Inn~stmellt Consultants ran he -.ftc-d through our Customer Service Center at 1-800~762-6111, Ollr w("bsile at www.pncbrokeragc.com or at allY PNC Bank :1(11 orfice. ecking Account Summary lunt number: 51~4019"G271 Account Link@ number: 0159181092 Erma M Hartz Shirley A Hartz ance SlInlmary Beginning balance 9,(}:20.lJtl Deposits and other additions 5,3~I:l.05 Checks and other deductions 2-W.27 Ending balance Please see the Activity Detail section for additional infonnation. 1'1,167.+1 Average monthly balance ] I,G68. 75 Charges and fees .00 IIsactiol1 Summary Checks paidl withdrawals BanI<: card/POS Account Information transactions assistance calls Teller transactions 2 o () 1 Total ATM transilctions PNC Bank MAC Other MAC ATM ATM transactions transactions Other ATM transactions o () 0 o 'ivity Detail ,osits and Other Additions There was 1 Deposit or Other Addition totaling $5.393.05. Amount Description ;:l 5,39:LO':; Deposit Rt~rcrence .l'\o. 027.:1.-l7789 cks 'r Amount 2:11.(12 Date paid OI,/:2G Reference number Check number 918 :I: Amount I-t.G5 Date paid 02/05 Reference number (J2:,r,jlgI5..j iJ2t2L.i9139 I in check sequence There were 2 checks listed totaling $246_27_ '--' For: 24.hour customer service: Call: l-BBB-PNC-BANK lily Balance Detail .("(:ollnl numllcr: 51.4019-6271- continued '1'...,. . . - L..I"I '-I 11 "- For the period 01/26/2001 to 02122/2001 ERMA M HARTZ Primary account number: 51-4019-6271 Page 2 of 2 . "2G Balance 8,i~~J.()1 Dale 02/0:1 Balance 8,77.:t.:1~1 Date 02./08 Balance 14,](;7.44 - - ----........- ......" ..... .............................. The Prudential Insurance Company of America Prudential Annuities Service Cen1er ?O 6.x 7960 ?hiladelphia. PA 19101 www.pruderrtlal.cofl\ Erma M. Hartz 9 Wayside Court Di1Isburg PA 17019 Contract Number: E0099274 May 11.2001 near Ms. Hartz, TIl3nk you for the opportunity to be of service to you. As requested, I am enclosing the conlrnct values for your Discovery Select Annuity. Dllte 02i27/200 1 Value $37,515.91 If yOu have any questions or concerns, ple..e don't hesitate to c.1I our Customer Service Center toll free at (888) 778-2888 from 8:00 a.m. to 8:00 p.m., Eastern time, ;-..1onday through Friday. To reach a separate number with a telecommunications device for the hearing irr,paired, you may call (800) 654-7637 between the hours of8:00 a.m. and 8:00 p.m. One of our Customer Service Repre;;entatives will be happy to assist you. Sincerely, . ~, " ;::' If.' ~":f.. ./'i:t:',~.,.:J...:',. Laura Dinmei( r Customer Set" ~'ice Coordinator A Pruoenti.al bu'i16$~ Registered Represerustl..e P~~~.lln...~'t~nt Managt"nent Ser{jce$lLC APrvdentiQi~!\y G:a1eYJ!JY Cenlef Thr~ - 14th .=11Xlf Newa/'l(, New Jluey 07~C2.~li77 (i73-)$C4~"2.4 Ca-porate Off~: ?'~. "road S1f~et. N?Wark. NJ 07102_ 37T7 ** TOTFt.. PAGE. 82 .',"' , ,~Prudential Prudentiallnvestmants Annuity Services PO Box 14215 Naw Brunswick, NJ OB906-4215 (BBB) JBB-2BBB Erma M Hartz 9 Wayside Ct Dillsburg, PA 17019 Contract Number: E0099274 November 15, 1999 Dear Ms, Hartz: Thank you for your recent inquiry concerning the value of your Discovery Select. As of November 12, 1999, tbe Contract Fund Value was: Investment Option acc Accumulation Trust - Managed T, Rowe Price Equity Inc. Portfolio Prudential Diversified Bond Prudential Jennison Value $ 9,862.25 $ 20,466.47 $ 36,174.87 $ 38,867.61 Total Contract Fund Value $ 105,371.20 Please keep in mind, if you surrender this contract you will lose the right to future annuity benefits under the contract. In addition, all or part of the distribution may be subject to federal and/or state income tax. You may also be subject to a 10 percent penalty tax for early withdrawal. You may want to consult with your tax adviser if you have any questions concerning the applicable tax treatment, as Prudential cannot offer tax advice, If you have any questions or concerns, please don't hesitate to call our Customer Service Center toll free at (888) 778-2888 from 8:00 a,m. to 9:00 p.m., Eastern time, Monday through Friday. To reach a separate number with a telecommunications device for the hearing impaired, you may call (800) 654-7637 between the hours of 8:00 a.m. and 8:00 p.m. One of our Customer Service Representatives will be happy to assist you. Sincerely, Carol Regan Carol Regan customer service representative Registered Representative Prudentiallovestment Management Services LLC A Subsidiary olTha Prudential Insurance Company of America 100 Mulberry Street GateweyCenterThree-14thFloor Newark, NewJersey07102-4077 (973"02."24