HomeMy WebLinkAbout01-0476
Registe"- r Wills of Cumberland County, Pennsylvania
PETITION FOR GRANT OF LETTERS
Estate of
also known as
RICHARD FRANCIS GREEN
RICHARD F. GREEN
No.
, Deceased
Social Security No.
201-40-7517
Cathi J 0 Green
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(COMPLETE 'A' or 'B' BELOW:)
00 A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/are the executnafTl];dbc1 the last Will of
the Decedent, dated 07 /07 /19l9i~ codicil(s) dated None
State relevant circumstances, e.g., renunciation, death of executor, etc.
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the documents
offered for probate; was not the victim of a killing and was never adjudicated incompetent:
CLtWlB. (1 ,~K9J en! ILl qqq
YIVORr.b:
U
I-U-LlJl)(
B. Grant of Letters of Administration
(c.I.a.; d.b.n.c.t.a; pendente lite; durante absentia; durante minoritate)
Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) and
heirs:
I
Name
Relationship
Residence
I
(COMPLETE IN ALL CASES:) Attach additional sheets if necessary.
Decedent was domiciled at death in Cumber land
County, Pennsylvania with his/her last family
or principal residence at 441 N. River Street 2, Worm1e sbur
(list street, number, and municipa ity)
Decedent, then 50 years of age, died 04/24/200Jat Worm1eysburg, PA
(Location)
Decedent at death owned property with estimated values as follows:
(If domiciled in PAl All personal property
(If not domiciled in PAl Personal property in Pennsylvania
(If not domiciled in PAl Personal property in County
Value of real estate in Pennsylvania
$
$
$
$
12,000.00
situated as follows:
Wherefore, Petitioner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented with this Petition and the grant of
letters in the a ro riate form to the undersi ned:
Si nature
T ed or rinted name and residence
Cathi Jo Green {)rtV(
1 Mountainview ~, Mechanicsbur , PA
17050
IG -~c()'IL
Prepared by the Pennsylvania Bar Association
Copyright (c) 1996 fonn software only CPSystems, Inc.
Fonn RW-1 (1991)
Oath of Personal Representative
Commonwealth of Pennsylvania
County of Cumber land
The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true
and correct to the best of the knowledge and belief of Petitioner(s) and that, as personal representative(s) of
the Decedent, Petitioner(s) will well and truly administer the estate according to law.
Cath~e;& t F
Sworn to or affirmed and subscribed
~TH-
before me this --E'!f of
mfrLf
n
~I-OI- D4'1lP
No.
Estate of RICHARD FRANCIS GREEN
Deceased
04/24/2001
Social Security No:
201-40-75:1I:iateof Death:
AND NOW,
LlLJYl A If
2LjV (
, in consideration
of the Petition on the reverse side hereon, satisfactory proof having been presented before me,
IT IS DECREED that Letters ~tamentary @ministration
(c.t.a.; d.b.n.c.t.a.; pendente lite; durante absentia; durante minoritate)
are hereby granted to
Cathi Jo Green
in the above estate and that the instrument(s) dated
07/07/1997
FEES
Letters....... . $ 0iJ .(TD
Short Certificate( s) . $ 15.00
Renunciation. $ Attorney:
Affidavits ( $ 1.0. No:
Extra Pages ( IL) $ ~.()O Address:
Jeffrey R. Boswell, Esquire
Codicil. . . . . . . . . ., $
25444
Boswell Tintner Piccola Wickersh
315 N. Front Street
P. O. Box 741
Harrisburg, PA 17108-0741
JCP Fee. . . . . . . . .. $
0.00
Telephone:
717/236-9377
Inventory. . . . . . . . ., $
TOTAL. . . . . . . ., $
10(0 .00
~AtL A-rf-l.
Other . .. .. .. .... $
Preoared bv the PennSYlvania Bar Association 0015-) I ;\lIlll Il,; I I ~~h rnrm ~nftware only CPSystems, Inc.
Form RW-1 (1991)
HI05.R0'5 REV 9/86
This is to certify that the information here given is correctly copied fro~ an original certificate of death dul~ filed with me as
Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filmg.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $2.00
p
7297384
No.
i.l44 Rev. 1191
~~l~
APR 3 0 ZOOl
Date
COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
(Coroner)
F
SEX
a.Male
Green
DArE OF BIRTH
(Month. Day, Year)
UNDER 1 011(
Hours Minute.
BIRTHPLACE (CiIy and
State Of Foreign Cauntly)
PLAce OF DEATH (Check only one see instructions on other side)
HOSPITAl: OTHER:
Feb.24,1951 ChevVr.ty, MV 1llpO';.nto ERlOufpat;.nto llOAo =;0
~ ~ k
P OF DeATH FACILITY NAME (II not institulion, give IIreel and number)
~)o
C
Ie. Wormleysburg
lei.
KINO OF BUSlNESSIlNDUSTRY
DECEDENT'B USUAlllCClJAllTlON
~...=:~~=~
TeaehVr. 1.Education
DECEDENT'S IWUNG ADDRESS (SO..., Cilylbwo. SIato, Zip COde) DECEDENT'S
1 Mounta.i..n V.i..e.w VJt.i..ve, ~~~~:-NCE
h (See inslruclions
Mee alt.i..e.6bWtg, PA 17050 onothersidel
1~
_R'S NAME (n.... Middle, ltiI)
1. AJtthWt F. GJteen
~'BNAME(Typ-'pr",Q
Rebeee GJteen
DECEDENT'S EOUCArION
if h. r
Er.m.ntary/iW,p1)l1ary
(0-12)/;:-
13.
17.._
PA
17b.
CumbVr.tand
230.
TIME OF OEArH P rx . ORE PRONOUNCED DEAD (Month, Day. 'fea')
24. 10:00 P. M. al. April 25, 2001
27. PART I: Enter the diIeaaM, injurlea or compIicatlonI which caused the death. Do not enter the mode of dying, such as cardiac or respiralory arrest, shock or heart faHure.
LioI only ana couoo on ooch line.
..
b.
DUE 10 (OR AS A CONSEQUENCE OF):
e.
DUE 10 (OR AS A CONSEQUENCE OF):
d
WERE AUlOPSY FINDINGS
-.LABLE PRIOR 10
COMPLETION OF CAUSE
OFDEArH?
MANNER OF DEArH
DArE OF INJURY
(Month, Day, Year)
STATE FILE NUMBER
SOCIAL SECURITY NUMBER
DArE OF OERH (Month, Day. _)
.. April 24, 2001
3.
201-40-7517
Old
-..
mina
Iownship?
MARITAl. STRUS. Morrtod
N._Morriod. WIdowod,
(1~)7 1..V.i..~~~
17e.o ...._1_'" S.i..tVVr.
lwp.
SURVIVING SPOUSE
("-. givo_ name)
SpJr..i..n.g
citylboro.
a8.
, ApproxImolo
: inlerVaI between
I on... and death
I
i
NoD
c::p
0lIl0r Ilgnlt/cant __ contributing 10 doeth. but
not roouIIlng '" lho undortylng couoo given '" PART I.
TIME OF INJURY
INJURY Ar WORK?
DESCRIBE HON INJURY OCCURRED.
N.tur.1 0 Homicide 0
l'Il _nt 0 Pondlng Irwootigatkln ~ . M.
Yoa 0 No ~ _ 0 Could not be dot..mined o:..~ ~~~;,;tt hom.. 'orm. ..,.... 'actory. otftco
-. _. at. 300.
~~ (PhYlic*l certilyingcauaed deeIh when .noth8f physician has pronounced dearh and completed Item 23)
To..._..IllYIInowtodtIO._occurNdduolO...couoo(.)ondmo........._.................................................... .
"__ AND CERTII'YINCI PHYSIClAII (Ph~ boIh prorlOlll1Clng -. and cor1/fylng Iocau&8 01 dooth)
To..._..""IInowtodtIO.__....._._.ondp/oco.ondduolO...couoo(.lond...............tod........................, .
._ _ERICORONER
On ...._at_ ondIarlnveellga1lan.1n my opinion. deolll_...... _. _."" ploco. and duelolhe e.uoo(.) and
-..-................................................................................................. .
318.
RE
loll ~I /11 I
'1\1. 0 NoD
Coroner
DArE SIGNED (Month, Day. _)
o 1. A ril 27, 2001
NAME AND ADDRESS OF PERSON WHO COMPt.ITED OF OERH
<"em27)TypeorP'inl Michael L. Norris, Coroner
k7 6375 Basehore Road, Suite #1
JI'\ 32. Mechanicsburg, Pa. 17050
DArE FiLED (Month, Day. _)
00
I
M.
LAST WILL
OF
RICHARD FRANCIS GREEN
Jeffrey R. Boswell
BOSWELL, SNYDER, TINTNER & PICCOLA
315 North Front Street
Harrisburg, Pennsylvania 17101
.
T ABLE OF CONTENTS
LAST WILL AND TEST AMENT
OF
RICHARD FRANCIS GREEN
Introductory Clause
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
ITEM I
Direction to Pay Debts with Discretionary Refinancing by Personal
Representative .......................................... 1
ITEM II
Direction to Pay All Taxes from Residuary Estate
1
ITEM III
General Bequest of Personal and Household Effects With a Precatory
Memorandum. . . . . . . ... ..... . . . . . . . . . . . . . . . . . . . . . . . . . . " 2
ITEM IV
Residuary Gift to Wife; Contingent Gift to Trustee of The GREEN Family
Trust . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2
ITEM V
The GREEN Family Trust Introductory Provision ..................... 2
(1) Discretionary Payment of All Income to Children ................ 2
(2) Discretionary Payments of Principal for Children ................. 3
(3) Division into Shares for Children . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 3
(4) Upon Child's Death to Child's Issue .......................... 3
ITEM VI
Naming the Personal Representative, Personal Representative Succession,
Personal Representative's Fees and Other Matters. . . . . . . . . . . . . . .. 3
(1) Naming an Individual Personal Representative. . . . . . . . . . . . . . . . . .. 3
(2) Naming Individual Successor or Substitute Personal Representative ... 3
(3) Final Succession If All Individual Successor Personal
Representatives Cannot Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4
ITEM VII
Naming the Trustee, Trustee Succession, Trustee's Fees and Other Matters 4
(1) Naming Individuals as Trustee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . " 4
(2) Individual Trustees Succession . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4
(3) Final Succession If All Individual Trustees Cannot Act . . . . . . . . . . . " 4
(4) Limitations on Trustees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4
ITEM VIII
Definition of Personal Representative and Trustee . . . . . . . . . . . . . . . . . . . .. 4
ITEM IX
Powers for Personal Representative and Trustee ...................... 5
ITEM X
Marital Deduction Savings Clause for Outright Bequest ................. 5
ITEM XI
Provision for Trustee to Act as Trustee for Beneficiary Under Age Twenty-
One................................. ill................................................................ 5
ITEM XII
Trustee's Discretion in Making Payments to a Person Under Age Twenty-
One, Incompetent, or Incapacitated Person ..................... 6
ITEM XIII
Discretion Granted to Personal Representative in Reference to Tax
Matters. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 6
ITEM XIV
Appointment of Ancillary Representative . . . . . . . . . . . . . . . . . . . . . . . . . . .. 7
ITEM XV
Definition of Children .......................................... 7
ITEM XVI
ii
Definition of Words Relating to the Internal Revenue Code . . . . . . . . . . . . .. 7
ITEM XVII
Provision for Appointment by a Married Person of a Testamentary
Guardian. Appointment of a Successor or Substitute Testamentary
Guardian. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . " 8
ITEM XVIII
Statement by Testator of Intent Not to Exercise Power of Appointment 8
ITEM XIX
Simultaneous Death Provision Presuming Beneficiary Predeceases Testator 8
ITEM XX
Payment of Funeral Expenses and Expenses of Last Illness of Income
Beneficiary ............................................. 9
ITEM XXI
Perpetuities Savings Clause ...................................... 9
Testimonium Clause ........................................... 9
Attestation Clause ............................................. 9
iii
LAST WILL AND TEST AMENT
OF
RICHARD FRANCIS GREEN
Introductory Clause. I, RICHARD FRANCIS GREEN, a resident of and
domiciled in the Township of Silver Spring, County of Cumberland and Commonwealth
of Pennsylvania, do hereby make, publish and declare this to be my Last Will and
Testament, hereby revoking all Wills and Codicils at any time heretofore made by me.
I am married to CATHI JO GREEN.
I have two living children: REBECCA ANNE GREEN, born December 2, 1981
and KATI LYNNE GREEN, born April 8, 1984.
ITEM I
Direction to Pay Debts with Discretionary Refinancing by Personal
Representative. I direct that all my legally enforceable debts, secured and unsecured, be
paid as soon as practicable after my death. I direct that my Personal Representative
may cause any debt to be carried, renewed and refinanced from time to time upon such
terms and with such securities for its repayment as my Personal Representative may
deem advisable taking into consideration the best interest of the beneficiaries hereunder.
ITEM II
Direction to Pay All Taxes from Residuary Estate. I direct that all estate,
inheritance, succession, death or similar taxes (except generation-skipping transfer taxes)
assessed with respect to my estate herein disposed of, or any part thereof, or on any
bequest or devise contained in this my Last Will (which term wherever used herein shall
include any Codicil hereto), or on any insurance upon my life or on any property held
jointly by me with another or on any transfer made by me during my lifetime or on any
other property or interests in property included in my estate for such tax purposes be
paid out of my residuary estate and shall not be charged to or against any recipient,
beneficiary, transferee or owner of any such property or interests in property included in
my estate for such tax purposes.
Page 1
ITEM III
General Bequest of Personal and Household Effects With a Precatory
Memorandum. I give and bequeath all my personal and household effects of every kind
including but not limited to furniture, appliances, furnishings, pictures, silverware, china,
glass, books, jewelry, wearing apparel, boats, automobiles, and other vehicles, and all
policies of fire, burglary, property damage, and other insurance on or in connection with
the use of this property, to my wife, CATHI JO GREEN, if she shall survive me. If my
wife shall not survive me, I give and bequeath all this property to my children surviving
me, in approximately equal shares; provided, however, the issue of a deceased child
surviving me shall take per stirpes the share their parent would have taken had he or she
survived me. If my issue do not agree to the division of the property among themselves,
my Personal Representative shall make such division among them, the decision of my
Personal Representative to be in all respects binding upon my issue. I request that my
wife, my Personal Representative and my issue abide by any memorandum by me
directing the disposition of this property or any part thereof. This request is precatory
and not mandatory. If any beneficiary hereunder is a minor, my Personal Representative
may distribute such minor's share to such minor or for such minor's use to any person
with whom such minor is residing or who has the care or control of such minor without
further responsibility and the receipt of the person to whom it is distributed shall be a
complete discharge of my Personal Representative. The cost of packing and shipping
such property shall be charged against my estate as an expense of administration.
ITEM IV
Residuary Gift to Wife: Contingent Gift to Trustee of The GREEN Family Trust.
I give, devise and bequeath all the rest, residue and remainder of my property of every
kind and description (including lapsed legacies and devises) wherever situate and
whether acquired before or after the execution of this Will, to my wife, CATHI 10
GREEN, if she shall survive me. If she shall not survive me, then I give, devise and
bequeath all of the property to the Trustee of the GREEN Family Trust. The GREEN
Family Trust shall be administered as hereinafter set forth.
ITEM V
The GREEN Family Trust Introductory Provision. The GREEN Family Trust
shall be held, administered and distributed as follows:
(1) Discretionary Payment of All Income to Children. Commencing with the
date of my death, my Trustee shall pay to or apply for the benefit of anyone or more of
my children, until division into shares for children as hereafter provided all of the net
income from the GREEN Family Trust in convenient installments in such shares and
proportions as my Trustee in its sole discretion shall determine primarily for the medical
care, education, support and maintenance in reasonable comfort of my children, taking
Page 2
into consideration to the extent my Trustee deems advisable, any other income or
resources of my children known to my Trustee.
(2) Discretionary Payments of Principal for Children. Prior to division into
shares for children as hereafter provided, my Trustee may pay to or apply for the benefit
of anyone or more of my children such sums from the principal of the GREEN Family
Trust in such shares and proportions as in its sole discretion shall be necessary or
advisable from time to time for the medical care, education, support and maintenance in
reasonable comfort of my children, taking into consideration to the extent the Trustee
deems advisable, any other income or resources of my children known to my Trustee.
Any payment or application of benefits for a child of mine pursuant to this Paragraph
shall be charged against this Trust as a whole rather than against the ultimate
distributive share of the beneficiary to whom or for whose benefit the payment is made.
(3) Division into Shares for Children. Upon or after the death of my wife and
me, when no child of mine is living who is under the age of Twenty-five (25) years, my
Trustee shall divide this Trust as then constituted into equal separate shares so as to
provide One (1) share for each then living child of mine and One (1) share for each
deceased child of mine who shall leave issue then living. Each share shall be distributed
or retained in Trust as hereinafter provided.
(4) Upon Child's Death to Child's Issue. After division into shares for
children, upon the death of a child of mine prior to complete distribution of his or her
share, the undistributed balance of the child's share shall be distributed per stirpes to his
or her then living issue, or in default of such issue, per stirpes to my then living issue.
Provided, however, that if any portion of the share would otherwise be distributed to a
person for whose benefit a trust is then being administered under this the GREEN
Family Trust, that part shall instead be added to that trust and shall thereafter be
administered and distributed according to its terms.
ITEM VI
Naming the Personal Representative. Personal Representative Succession.
Personal Representative's Fees and Other Matters. The provisions for naming the
Personal Representative, Personal Representative succession, Personal Representative's
fees and other matters are set forth below:
(1) Naming an Individual Personal Representative. I hereby nominate,
constitute, and appoint as Personal Representative of this my Last Will and Testament
CATHI JO GREEN and direct that she shall serve without bond.
(2) Naming Individual Successor or Substitute Personal Representative. If my
individual Personal Representative should fail to qualify as Personal Representative
hereunder, or for any reason should cease to act in such capacity, the successor or
Page 3
substitute Personal Representatives who shall also serve without bond shall be ROBERT
M. GILBERT and JOAN GILBERT, of 24 Goldenrod Drive, Carlisle, PA 17013. If
any individual Personal Representative named herein should fail to qualify as Personal
Representative hereunder, or for any reason should cease to act in such capacity, the
remaining individual Personal Representatives named herein shall continue to serve
without a successor or substitute.
(3) Final Succession If All Individual Successor Personal Representatives
Cannot Act. If all my individual successor Personal Representatives should fail to
qualify as Personal Representative hereunder, or for any reason should cease to act in
such capacity, then the successor or substitute Personal Representatives who shall also
serve without bond shall be ALBERT SNYDER and ANNELLE SNYDER, of Star
Route, H. C. Box 68, Pleasant Mount, PA 18453. If any of them should fail to qualify
or for any reason should cease to act in such capacity the remaining individual Personal
Representatives shall serve without a successor.
ITEM VII
Naming the Trustee. Trustee Succession. Trustee's Fees and Other Matters. The
provisions for naming the Trustee, Trustee succession, Trustee's fees and other matters
are set forth below:
(1) Naming Individuals as Trustee. I hereby nominate, constitute, and appoint
as Trustees of this my Last Will and Testament ROBERT M. GILBERT and JOAN
GILBERT and direct that they shall serve without bond.
(2) Individual Trustees Succession. If any individual Trustee should fail to
qualify as Trustee hereunder, or for any reason should cease to act in such capacity, the
remaining individual Trustees shall continue to serve without a successor or substitute.
(3) Final Succession If All Individual Trustees Cannot Act. If all my individual
Trustees should fail to qualify as Trustee hereunder, or for any reason should cease to
act in such capacity, then the successor or substitute Trustees who shall also serve
without bond shall be ALBERT SNYDER and ANNELLE SNYDER. If any of them
should fail to qualify or for any reason should cease to act in such capacity the remaining
individual Trustees shall serve without a successor.
(4) Limitations on Trustees. No person who at any time is acting as Trustee
hereunder shall have any power or obligation to participate in any discretionary authority
which I have given to the Trustee to pay principal or income to such person, or for his or
her benefit or in relief of his or her legal obligations.
Page 4
ITEM VIII
Definition of Personal Representative and Trustee. Whenever the word "Personal
Representative" and/ or the word "Trustee", or any modifying or substituted pronoun
therefor are used in this my Will, such words and respective pronouns shall include both
the singular and the plural, the masculine, feminine and neuter gender thereof, and shall
apply equally to the Personal Representative and/ or Trustee named herein and to any
successor or substitute Personal Representative and! or Trustee acting hereunder, and
such successor or substitute Personal Representative and! or Trustee shall possess all the
rights, powers and duties, authority and responsibility conferred upon my Personal
Representative and! or Trustee originally named herein.
ITEM IX
Powers for Personal Representative and Trustee. By way of illustration and not
of limitation and in addition to any inherent, implied or statutory powers granted to
Personal Representatives and Trustees generally, my Personal Representative and
Trustee is specifically authorized and empowered with respect to any property, real or
personal, at any time held under any provision of this my Will: to allot, allocate between
principal and income, assign, borrow, buy, care for, collect, compromise claims, contract
with respect to, continue any business of mine, convey, convert, deal with, dispose of,
enter into, exchange, hold, improve, incorporate any business of mine, invest, lease,
manage, mortgage, grant and exercise options with respect to, take possession of, pledge,
receive, release, repair, sell, sue for, to make distributions or divisions in cash or in kind
or partly in each without regard to the income tax basis of such asset, and in general, to
exercise all the powers in the management of my Estate which any individual could
exercise in the management of similar property owned in his or her own right, upon such
terms and conditions as to my Personal Representative and Trustee may seem best, and
to execute and deliver any and all instruments and to do all acts which my Personal
Representative and Trustee may deem proper or necessary to carry out the purposes of
this my Will, without being limited in any way by the specific grants of power made, and
without the necessity of a court order.
ITEM X
Marital Deduction Savings Clause for Outright Bequest. It is expressly provided
that the grant of rights, powers, privileges and authority to my Personal Representative
in connection with the imposition of duties upon my Personal Representative by any
provision of this my Will or by any statute relating thereto shall not be effective if and to
the extent that the same, if effective, would disqualify the marital deduction as provided
for herein. It is expressly provided that my Personal Representative shall not in the
exercise of its discretion make any determination inconsistent with the foregoing
intention.
Page 5
ITEM XI
Provision for Trustee to Act as Trustee for Beneficiary Under Age Twenty-One.
If any share hereunder becomes distributable to a beneficiary who has not attained the
age of Twenty-one (21), such share shall immediately vest in the beneficiary, but
notwithstanding the provisions herein, my Trustee shall retain possession of the share in
trust for the beneficiary until the beneficiary attains the age of Twenty-one (21), using so
much of the net income and principal of the share as my Trustee deems necessary to
provide for the medical care, education, support and maintenance in reasonable comfort
of the beneficiary, taking into consideration to the extent my Trustee deems advisable
any other income or resources of the beneficiary or his or her parents known to my
Trustee. Any income not so paid or applied shall be accumulated and added to principal.
The beneficiary's share shall be paid over and distributed to the beneficiary upon
attaining age Twenty-one (21), or if he or she shall sooner die, to his or her personal
representatives. My Trustee shall have with respect to each share so retained all the
powers and discretions it had with respect to the trusts created herein generally.
ITEM XII
Trustee's Discretion in Making Payments to a Person Under Age Twenty-One.
Incompetent. or Incapacitated Person. In case the income or principal payment under
any trust created hereunder or any share thereof shall become payable to a person under
the age of Twenty-one (21), or to a person under legal disability, or to a person not
adjudicated incompetent, but who, by reason of illness or mental or physical disability, is,
in the opinion of my Trustee unable properly to administer such amounts, then such
amounts shall be paid out by my Trustee in such of the following ways as my Trustee
deems best: (1) directly to the beneficiary; (2) to the legally appointed guardian of the
beneficiary; (3) to some relative or friend for the medical care, education, support and
maintenance in reasonable comfort of the beneficiary; (4) by my Trustee using such
amounts directly for the beneficiary's care, support and education; (5) to a custodian for
the beneficiary under the Uniform Gifts or Transfers to Minors Act.
ITEM XIII
Discretion Granted to Personal Representative in Reference to Tax Matters. My
Personal Representative as the fiduciary of my estate shall have the discretion, but shall
not be required when allocating receipts of my estate between income and principal, to
make adjustments in the rights of any beneficiaries, or among the principal and income
accounts to compensate for the consequences of any tax decision or election, or of any
investment or administrative decision, that my Personal Representative believes has had
the effect, directly or indirectly, of preferring one beneficiary or group of beneficiaries
over others; provided, however, my Personal Representative shall not exercise its
discretion in a manner which would cause the loss or reduction of the marital deduction
as may be herein provided. In determining the state or federal estate and income tax
Page 6
liabilities of my estate, my Personal Representative shall have discretion to select the
valuation date and to determine whether any or all of the allowable administration
expenses in my estate shall be used as state or federal estate tax deductions or as state
or federal income tax deductions and shall have the discretion to file a joint income tax
return with my wife.
ITEM XIV
Appointment of Ancillary Representative. If it becomes necessary for a
representative of my estate to qualify in any jurisdiction other than the State of my
domicile at the time of my death, then to the extent that I may legally do so, I hereby
nominate, constitute, and appoint my Personal Representative named in this Will as my
representative in such jurisdiction and direct that such Personal Representative shall
serve without bond. If for any reason my Personal Representative is unable or unwilling
to serve as such representative or cannot qualify as such representative, then I hereby
appoint my Personal Representative named herein to designate (to the extent that it may
legally do so) a person or a corporation to serve as my representative and request that
such person or corporation shall serve without bond. Any representative named as
provided herein (to the extent that it may legally do so) shall have in such jurisdiction all
the powers and duties conferred or imposed on my Personal Representative by the
provisions of this Will.
ITEM XV
Definition of Children. For purposes of this Will, "children" means the lawful
blood descendants in the first degree of the parent designated; and "issue" and
"descendants" mean the lawful blood descendants in any degree of the ancestor
designated; provided, however, that if a person has been adopted, that person shall be
considered a child of such adopting parent and such adopted child and his or her issue
shall be considered as issue of the adopting parent or parents and of anyone who is by
blood or adoption an ancestor of the adopting parent or either of the adopting parents.
The terms "child," "children:' "issue," "descendant" and "descendants" or those terms
preceded by the terms "living" or "then living" shall include the lawful blood descendant
in the first degree of the parent designated even though such descendant is born after
the death of such parent.
The term "per stirpes" as used herein has the identical meaning as the term
"taking by representation" as defined in the Pennsylvania Probate Code.
ITEM XVI
Definition of Words Relating to the Internal Revenue Code. As used herein, the
words "gross estate," "adjusted gross estate," "taxable estate," "unified credit," "state death
tax credit," "maximum marital deduction," "marital deduction," "pass," and any other
Page 7
word or words which from the context in which it or they are used refer to the Internal
Revenue Code shall have the same meaning as such words have for the purposes of
applying the Internal Revenue Code to my estate. For purposes of this Will, my
"available generation-skipping transfer exemption" means the generation-skipping transfer
tax exemption provided in section 2631 of the Internal Revenue Code of 1986, as
amended, in effect at the time of my death reduced by the aggregate of (1) the amount,
if any, of my exemption allocated to lifetime transfers of mine by me or by operation of
law, and (2) the amount, if any, I have specifically allocated to other property of my
gross estate for federal estate tax purposes. For purposes of this Will if at the time of
my death I have made gifts with an inclusion ratio of greater than zero for which the gift
tax return due date has not expired (including extensions) and I have not yet filed a
return, it shall be deemed that my generation-skipping transfer exemption has been
allocated to these transfers to the extent necessary (and possible) to exempt the
transfer(s) from generation-skipping transfer tax. Reference to sections of the Internal
Revenue Code and to the Internal Revenue Code shall refer to the Internal Revenue
Code amended to the date of my death.
ITEM XVII
Provision for Appointment by a Married Person of a Testamentary Guardian.
Appointment of a Successor or Substitute Testamentary Guardian. If my wife shall
predecease me, or if my wife dies after my death without having appointed a
testamentary guardian for any minor child or children of ours, then I hereby nominate,
constitute, and appoint THOMAS GREEN and CINDY GREEN as testamentary
guardian of the person and the property of such minor child or children and to the
extent allowed by law direct that such guardian shall serve without bond. If THOMAS
GREEN and CINDY GREEN dies, resigns, or refuses or is otherwise unable to act,
then I appoint ROBERT M. GILBERT and JOAN E. GILBERT as testamentary
guardian of the person and property of such minor child or children and direct that such
guardian shall also serve without bond.
ITEM XVIII
Statement by Testator of Intent Not to Exercise Power of Appointment. I hereby
refrain from exercising any power of appointment that I may have at the time of my
death.
ITEM XIX
Simultaneous Death Provision Presuming Beneficiary Predeceases Testator. If
any beneficiary and I should die under such circumstances as would make it doubtful
whether the beneficiary or I died first, then it shall be conclusively presumed for the
purposes of this Will that the beneficiary predeceased me.
Page 8
ITEM XX
Payment of Funeral Expenses and Expenses of Last Illness of Income Beneficiary.
On the death of any person entitled to income or support from any Trust hereunder, my
Trustee is authorized to pay the funeral expenses and the expenses of the last illness of
such person from the principal of the Trust from which such person was entitled to
income or support.
ITEM XXI
Perpetuities Savings Clause. Notwithstanding anything herein to the contrary, the
trusts created hereunder shall terminate not later than Twenty-one (21) years after the
death of the last survivor of my wife and issue living on the date of my death, when my
Trustee shall distribute each remaining trust hereunder to the beneficiary or beneficiaries
of the current income thereof, and if there is more than one beneficiary, in the
proportion in which they are beneficiaries or if no proportion is designated in equal
shares to such beneficiaries.
Testimonium ClarN WITNESS WHEREOF, I have hereunto set my hand
and affIxed my seal this day of July, 1997.
~f~ ,/;L,(SEALl
ICHARD FRANCIS GREEN
Attestation Clause. The foregoing Will was this 711... day of July, 1997, signed, sealed,
published and declared by the Testator as and for his Last Will and Testament in our
presence, and we, at his request and in his presence, have hereunto subscribed our names as
witnesses on the above date.
~~~
,
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of
Page 9
PROOF OF WILL
Commonwealth of Pennsylvania
Self-Proving Affidavit
County of Dauphin
We, RICHARD FRANCIS GREEN, and Jeffrey R. Boswell and
Connie L. Hardy ,the Testator 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 Testator signed and executed the instrument as his
Last Will and that he had signed willingly (or willingly directed another to sign for him),
and that he executed it as his free and voluntary act for the purposes therein expressed,
and that each of the witnesses, in the presence and hearing of the Testator, signed the
Will as witness and to the best of our knowledge the Testator was at that time eighteen
years of age or older, of sound mind, and under no constraint or undue influence.
t '1 eff
. ,<-o~ //~ //~
RICHARD FRANCIS GREEN
~
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Wltne
Subscribed, sworn to, and acknowledged before me by RICHARD FRANCIS
GREEN, the Testator and subscribed and sworn to before me by
Jeffrey R. Boswell and Connie L. Hardy , witnesses, this .2th. day
of July, 1997.
~ ~
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Notary Public for Pennsylv ia
My Commission Expires: /~//~/9 J
NOTARiAl'SEAl. . l
SARAH E !\PPI~f3'i, NO~lfY ;~~bl,l~o81
M'i ComrnissicnLxpifesL f.~C. _!,j, \'y, 'I..
Harrisburg, PI; OGuprHrl COIHl.!!__,-o
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Page 10
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M:home/JRB/Estate/Green Richard FSA.wpd DRAFT #4
August 14,2003
ESTATE SETTLEMENT AGREEMENT
-t/v
THIS AGREEMENT is made the J. U - day of August, 2003, by and among CA THI
JO GREEN, Executrix of the Estate of Richard Francis Green, Deceased (herein referred to as
Executrix), and CA THI JO GREEN, of 1 Mountainview Drive, Mechanicsburg, P A 17050, former
wife of the decedent, REBECCA ANNE GREEN, of 1 Mountainview Drive, Mechanicsburg, PA
17050, and KATI LYNNE GREEN, of 1 Mountainview Drive, Mechanicsburg, PA 17050,
daughters of the decedent and beneficiaries of the estate (herein collectively referred to as the
Beneficiaries ).
In accordance with their desire that the administration of the Estate of Richard
Francis Green be completed, and in consideration of the mutual covenants expressed, the stated
Executrix and Beneficiaries, and intending to be legally bound agree, as follows:
1. Richard Francis Green died on April 24, 2001.
2. The Estate of Richard Francis Green is now in the process of administration, with Letters
Testamentary having been duly granted to the stated Executrix by the Register of Wills of
Cumberland County on May 16, 2001. Jeffrey R. Boswell, Esquire has served as legal counsel.
3. In May, 2001, counsel prepared and arranged for the publication of the required legal
advertisements, which proofs of publication are attached as Exhibit "A" and Exhibit "B."
4. The Executrix established an estate checking account at Waypoint Bank and paid all
proper debts as listed in the Inheritance Tax Return.
5. The beneficiaries acknowledge receipt of Rule 5.6 notices regarding notice of their
beneficial interest in the estate. Counsel prepared a Certification of Notice Under Rule 5.6(a) and
filed same with the Register of Wills of Cumberland County on August 22, 2001. The parties
acknowledge that the Rule 5.6 notice was served upon Kati Lynne Green, c/o Cathi Jo Green,
Guardian of Kati Lynne Green, a minor.
6. Rebecca A. Green was born on December 2, 1981.
7. Kati Lynne Green was born on April 8, 1984.
8. The decedent, who is also known as Richard F. Green, was divorced from Cathi Jo Green
on January 11,2001, as per the Decree in Divorce in the Court of Common Pleas of Cumberland
County, No. 5895-99 Civil Term. According to the stated Decree in Divorce, the Court retained
jurisdiction of no claims raised of record in the divorce action.
9. The stated Richard F. Green and Cathi Jo Green executed a Marriage Settlement
Agreement (hereinafter referred to as the "MS Agreement") on November 28, 2000, entered of
record in the stated action on November 29, 2000, which MS Agreement is attached and
incorporated as Exhibit "C."
10. According to paragraph 3 ofthe stated MS Agreement, the stated Richard F. Green and
Cathi Jo Green agreed that a copy of the agreement may be incorporated by reference into the
divorce judgment or decree, but shall not be regarded as a merger, it being the specific intent ofthe
parties to permit this MS Agreement to survive any judgment and to be forever binding and
conclusive upon the parties.
11. According to paragraph 11 ofthe stated MS Agreement, the stated Richard F. Green and
Cathi Jo Green agreed to waive any rights that they currently had in each other's employment
benefits, including, but not limited to both parties' pensions, retirement plans, Incentive Savings
Plans, and Tax Sheltered Annuities, except as relates to Higher Education for the couple's children.
12. Thereafter, in paragraph 19 ofthe stated MS Agreement concerning Higher Education,
the stated Richard F. Green and Cathi Jo Green acknowledge a mutual fund valued at approximately
$20,000 that was jointly titled and that was to be used for higher education. According to that
paragraph, Richard F. Green also acknowledged his retirement fund valued at $40,000. Cathi Jo
Green stated her desire that her 50% portion of the fund be used for education purposes.
13. According to paragraph 17 of the stated MS Agreement, Richard F. Green and Cathi Jo
Green agreed that Cathi Jo Green would have primary and legal custody of the children, Rebecca
Green and Kati Green.
14. The mutual funds owned jointly by Richard F. Green and Cathi Jo Green were
comprised of various Delaware Investment accounts which had the following total value at
decedent's death: Growth and Income Fund B, $3,173.93; Devon Fund B, $317.26, and Fund 144,
$426.03, which total value has been used for Rebecca's education expenses.
15. On August 14,2000, the Commonwealth of Pennsylvania Public School Employees'
Retirement System notified Richard F. Green of his initial retirement benefit based on his option
selection and the latest salaries and service on file with the Public School Employees' Retirement
System. According to this notice, the maximum single life annuity entitled Mr. Green to a monthly
benefit of$702.26 beginning on September 29, 2000. He was also entitled to payments for $40,000
and for $11,600.80, as stated in the letter which is attached and incorporated at Exhibit "D."
16. Mr. Green used the $11,600.80 payment for various expenses during his lifetime.
17. Mr. Green effected the rollover ofthe $40,000 to Horace Mann Life Insurance Co. IRA
#050358080.
18. Richard F. Green established a retirement annuity contract on February 10, 1993,
#0506405200 which contract had a cash value at his death of$48,057.98. According to the annuity
application, which is attached and incorporated as Exhibit "E," the primary beneficiary was Cathi
Jo Green. This beneficiary designation was not changed after the divorce, as Cathi Jo Green was
his beneficiary.
19. Horace Mann Insurance Co. acknowledged the termination of Richard F. Green's
annuity contracts, #0570358080, with a total cash value of $40,000, to which it added interest of
$111.91, and #0506405200, that had a total cash value of $48,057.98, to which it added interest of
$134.45, which termination letter is attached and incorporated as Exhibit "F," which accounts were
combined to create a new annuity contract, No. S20279, with a contract value of $88,304.34,
according to the Annuity Income Statement of Benefits, which is attached and incorporated as
Exhibit "G," with Cathi Jo Green as the annuitant and Rebecca A. Green and Kati L. Green as the
primary beneficiaries of that new account.
20. On August 3, 2001, the stated Cathi Jo Green provided a statement to Horace Mann
Insurance Co. which provided, as follows: "When Richard F. Green designated a beneficiary of his
tax shelter and retirement rollover, upon his death the intended beneficiary was to be myself, Cathi
Green, even upon separation or divorce," which statement is attached and incorporated as Exhibit
"H. "
21. Prior to his death, Richard F. Green did not receive payments from either of the two
annuity contracts. With regard to annuity contract #0570358080, which had a value of $40,000,
Richard 1. Green executed an Individual Retirement Annuity Application for rollover ofthat account
to Horace Mann Life Insurance Company naming Cathi Jo Green as primary beneficiary and
Rebecca A. Green and Kati Green as contingent beneficiaries, which application is attached and
incorporated as Exhibit "I."
22. Cathi Jo Green, Rebecca A. Green, and Kati L. Green acknowledge the existence ofthe
Horace Mann annuity contract S20279, with an initial contract value of$88,304.34, as to which the
stated Cathi Jo Green is, according to said contract, entitled to receive 120 monthly payments with
the current monthly payment (valued at October, 2001) of$928.03.
23. The stated parties acknowledge Cathi Jo Green's responsibility to provide for higher
education, as intended by the decedent, and as recognized in the Marriage Settlement Agreement.
24. The parties acknowledge and agree that the beneficiary designation for the two
retirement annuity contracts, No. 0570358080 and No. 0506405200, listed Cathi Jo Green as
primary beneficiary, which designation was never changed after the divorce and prior to decedent's
death.
25. The stated Cathi Jo Green acknowledges her individual responsibility to abide by the
Marriage Settlement Agreement to use Richard 1. Green's retirement fund, including her portion
thereof for higher education purposes.
26. After review by the Executrix, Counsel filed the Inventory and the Pennsylvania
Inheritance Tax Return on August 27,2003, paying inheritance tax due to the Register of Wills,
Agent, for the Pennsylvania Department of Revenue, which documents are attached as Exhibits "J"
and "K."
27. The parties acknowledge and agree that distribution to them of the equal distributive
shares will be made to Cathi Jo Green for decedent's daughters through bank accounts created for
their benefit after receipt of the Notice of Inheritance Tax Appraisement from the Pennsylvania
Department of Revenue, noting that the PA Inheritance Tax Return (Revenue - 1500) is accepted,
with the tax paid in full.
28. The parties agree that the general bequest of personal and household effects, according
to Item III ofthe Last Will and Testament, was made to Rebecca A. Green and Kati L. Green, as the
stated bequest to the wife abates due to the divorce prior to decedent's death. The parties
acknowledge and agree that the decedent's small apartment contained a limited amount of furniture
which had no monetary value.
29. The parties acknowledge and agree that the residuary gift to wife abates because of the
decedent's divorce prior to death, thereby requiring all the rest, residue, and remainder of decedent's
property to be given to the Green Family Trust (which will be separate bank accounts held by Cathi
Jo Green as trustee for each daughter) to be used for decedent's children for medicare care,
education, support, and maintenance until such time when both children are age twenty-five (25).
30. The Executrix filed appropriate fiduciary income tax returns, with respect to
decedent's 2001 income tge parties agree that decedent's estate had no reportable income in 2202
and 2003.
31. The parties acknowledge and agree that all taxes and administrative expenses have
been paid and that the net assets of the estate, as contained in the estate checking account shall be
distributed as set forth in the Schedule of Distribution, upon the execution ofthis agreement and the
Acknowledgment Release document.
32. The parties agree that Jeffrey R. Boswell, Esquire, as counsel, will file this Estate
Settlement Agreement with the Register of Wills to be made part of the official record and that
counsel has explained in a letter dated August 26, 2003, addressed to the parties the effect ofthe "at
risk" distribution contemplated to be made pursuant to this agreement.
33. Counsel will prepare and file with the Register of Wills a rule 6.12 report noting
that the estate administration is complete after the occurrence of the following events:
(a) the receipt of the notice of inheritance tax appraisement issued by the
Pennsylvania Department of Revenue showing the tax and any penalities, and
interest are fully paid.
(b) final distribution to Beneficiaries of any remaining funds after payment of
reserve amounts.
34. The parties, and each of them, hereby forever fully release, compromise, settle, and
discharge any and all claims, demands, actions, or causes of action, legal or equitable, absolute or
contingent, vested or hereafter to accrue, which any ofthem may have against any other party hereto
or against the Estate of Richard F. Green, Deceased, or the agents of the estate, including
accountants and attorneys, by reason of any matter, cause or things growing out of or relating to any
property or assets of said estate, or growing out of or relating to any act of the Executrix in her
administration of the said estate, even if attributable to negligence, and agree that any period of the
limitation of actions for the collection of any erroneous distribution or distributions shall commence
only at such time as the Executrix shall have obtained actual knowledge of said erroneous
distribution or distributions, which period shall end two (2) years after actual discovery.
35. The beneficiaries acknowledge that ifit is determined that ifthere is presented any
tax liability (including interest and penalties) or any other proper debt, CATHI JO GREEN,
individually will pay such additional taxes or debts.
36. The parties agree to execute such additional documents and releases as the Executrix
may submit to them in order to complete any administration details to confirm her discharge from
any further liability to the parties in connection with the said estate.
37. This agreement may be executed in multiple counterparts and, when so executed,
shall be binding upon all parties, and their respective heirs, next of kin, personal representatives, and
assIgns.
IN WITNESS WHEREOF, the parties have hereunto set their hands and seals the day and
year first above-written.
DATE:
7/YV-03
Cathi~x#f~1 ~
DATE:
'(,,30,03
DATE: 0 - 2f.o -0 '3
-1<.L~ a. ..j~
Rebecca A. Green, as an Individual Beneficiary
DATE: g -J-U -03
((jjt' d. MiJl
Kati L. Green, as an Individual Beneficiary
ESTATE OF RICHARD F. GREEN. DECEASED
SCHEDULE OF DISTRIBUTION
L
Waypoint Bank
Estate Checking Account No.1 00311968
Balance as of August 26, 2003
Less Inheritance Tax Due (check #116)
$ 5,012.85
(298.79)
Less Income Tax Preparation to
Boswell, Tintner, Piccola & Wickersham
(check # 11 7)
TOTAL
(300.00)
$ 4,414.06
II. TOTAL CASH AMOUNT TO BE DISTRIBUTED, $ 4,414.06
as per paragraph 27, assuming PA Inheritance Tax
Return is accepted, as filed
CASH AMOUNT TO BE DISTRIBUTED (50%)
To Cathi Jo Green, Trustee for Rebecca A. Green
(check # 118) (2,207.03)
CASH AMOUNT TO BE DISTRIBUTED (50%)
To Cathi Jo Green, Trustee for Kati Lynne Green
(check # 119) (2207.03)
0.00
III. PREVIOUS DISTRIBUTIONS:
Delaware Investment/account, total value owned
jointly by Richard F. Green and Cathi Jo Green:
Total value used for Rebecca A. Green,
education expenses, as per paragraph 14 $3.861.22
Furniture and personal property of insignificant monetary value:
Rebecca A. Green and Kati Lynne Green, as per
paragraph 28
0.00
PROOF OF PUBLICATION
GI/llo(
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State of Pennsylvania,
County of Cumberland.
Sherry Clifford, Classified Ad Manager of THE SENTINEL,
of the County and State aforesaid, being duly sworn, deposes and says that THE SENTINEL, a newspaper of
general circulation in the Borough of Carlisle, County and State aforesaid, was established December 13th,
1881, since which date THE SENTINEL has been regularly issued in said County, and that the printed notice
or publication attached hereto is exactly the same as was printed and published in the regular editions and
issues of THE SENTINEL on the following dates, viz
Copy of Notice of Publication
ESTATE NOTICE
NOTICE IS HEREBY GIV-
EN that the Register of
Wills has granted Letters
Testamentary to the per-
son named. All persons
having claims or
demands against the
estate are requested to
make known the claim
or demand, and all
persons indebted to the
estate are requested to
make payment, without
delay, to the Executrix
or to her attorneys
named below:
The Estate of RICHARD
FRANCIS GREEN, late
ofthe Borough of Worm-
leysburg, County of
Cumberland and State
of Pennsylvania.
Executrix: Cathi Jo Green
Attorney: Jeffrey R.
Boswell, Esquire
Boswell, Tintner, Piccola &
Wickersham
315 N. Front Street, P.O.
Box 741
Harrisburg, PA 17108-0741
May 23,30 & June 6, 2001
Affiant further deposes that he is not interested in
the subject matter of the aforesaid notice or
advertisement, and that all allegations in the
foregoing statement as to time, place and character
of publication are true.
Sworn to and subscribed before me this
day of June , 2001.
c5t<..wcilyt () . cVU/l/lUt-;
Notary Public
6th
My commission expires:
NOTARIAL SEAL
SHIRLEY O. DURNIN, Notary Public
Carlisle Bora., Cumberland Countll
M Commission Expires Au .9,2003
EXHIBIT
I
k
PROOF OF PUBLICATION OF NOTICE
IN CUMBERLAND LAW JOURNAL
(Under Act No. 587, approved May 16,1929), P. L.1784
STATE OF PENNSYLVANIA :
ss.
COUNTY OF CUMBERLAND :
Roger M. Morgenthal, Esquire, Editor of the Cumberland Law Journal, ofthe County
and State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland
Law Journal, a legal periodical published in the Borough of Carlisle in the County and State
aforesaid, was established January 2, 1952, and designated by the IP'i~l courts as the officiallegal
periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly
issued weekly in the said County, and that the printed notice or publication attached hereto is
exactly the same as was printed in the regular editions and issues of the said Cumberland Law
Journal on the following dates,
Viz
JUNE 1,2001
Affiant further deposes that he is authorized to verify this statement by the Cumberland
Law Journal, a legal periodical of general circulation, and that he is not interested in the subject
matter ofthe aforesaid notice or advertisement, and that all allegations in the foregoing
statements as to time, place and character of publication are
/
Roger M. Morgenthal, Editor
,
Green, Richard F., dec'd.
Late of the Borough ofWormleys-
burg.
Executrtx: Cathi Jo Green.
Attorneys: Jeffrey R. Boswell,
Esquire, Boswell, Tlntner, Piccola
& Wickersham. 315 N. Front
Street. P.O. Box 741, Harrtsburg,
PA 17108-0741.
SWORN TO AND SUBSCRIBED before me this
1 day of JUNE. 2001
NOTARIACSEAl
LOtS E. SNYDeR, ~ AaIc
My~~~Ccu1ty
........- Man:h 5, 2005
EXHIBIT
j~
CA THI JO GREEN,
Plaintiff
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANlA
V5.
No.
5895 - 99 Civil Term
-c: .
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RICHARD F. GREEN,
Defendant
ACTION IN DIVORCE
r:'
:"-;:.-~
.;.::.:-
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MARRIAGE SETTLEMENJ AGR~EMENI
THIS AGREEMENT, made thi~ g14 day of M' '" - r> l/"l , 2000, by and between,
CATHI JO GREEN, of Silver Spring Township, Cumberland ~~ia, hereinafter referred to
as "WIFE", and RICHARD F. GREEN, of Silver Spring Township, Cumberland County, Pennsylvania,
hereinafter referred to as "HUSBAND".
WITNESSETH:
WHEREAS, Husband and Wife were lawfully married on December 30,1972, in Bucks County,
Pennsylvania, and; .
WHEREAS, there were two children born of this marriage;
WHEREAS, differences, disputes, and difficulties have arisen between the parties and it is the
intention of Husband and Wife to live separate and apart for the rest of their natural lives, and the parties
- desire to settle their respective financial property rights and obligations as between each other,
WHEREAS, HUSBAND is PRO SE and has personally chosen to NOT retain an attorney. The
Wife has employed and had the benefit or counsel of Jane Adams, Esquire, as her attorney.
Each party has carefully and completely read this agreement in its entirety. Each party, after
reading this agreement, understands the agreement and its legal effect. Each party is entering into this
agreement freely and voluntarily after reading it, and the execution of this agreement is not the result of
duress or undue influence.
Each party warrants that he or she has made a full and fair disclosure of income, assets, and their
valuation prior to the execution of this Agreement as well as an}' oJherfactr~latilJgJnJ!IlYway to the
subject matter of this agreement.
~
Each party hereto still desires to execute this Agreement, acknowledge that the terms and
conditions set forth herein are equitable to each of the parties and waives his or her respective right to
have the Court of Commons Pleas of Cumberland County or any other Court of competent jurisdiction
make any determination or Order affecting the respective party's right to a divorce, alimony, alimony
pendente lite, equitable distribution of all martial property, counsel fees, and costs of litigation.
NOW THEREFORE, Wife and Husband, each intending to be legally bound, hereby covenant
and agree as follows:
EXHIBIT
I C_
.......,..-- ....--~...- -,..
_,..~_ _.'""...._A~~~.~......
1. SEPARATION. That the parties intend to maintain separate and permanent domiciles and to
live apart from each other. It is the intention and purpose of this agreement to set forth their respective
rights and duties while they continue to live apart from each other. Whereas a Complaint in Divorce was
filed, both parties will agree and sign the paperwork to complete a No-Fault Divorce after the applicable
ninety (90) day time period has run. It is the intention of the parties that the division of property in this
agreement shall be final and forever determine the parties respective rights. The division of existing
marital property is not intended by the parties to constitute in any way a sale or exchange of assets.
2. INTERFERENCE. Further, the parties agree to continue living separately and apart from each
other at any place or places that he or she may select. Neither party shall harass, annoy, injure, threaten,
or interfere with the other party in any manner whatsoever. Each party may carry on and engage in any
employment, profession, business or other activity as he or she may deem advisable for his or her sole
use and benefit. Neither party shall interfere with the uses, ownership, enjoyment, or disposition of any
property now owned and not specified herein or property hereafter acquired by the other.
3. SUBSEQUENT DIVORCE. The parties hereby acknowledge that WIFE has filed a Complaint
in Cumberland County, claiming that the marriage is irretrievably broken under the no-fault mutual consent
provision of Section 3301 (c) of the Pennsylvania Divorce Code. WIFE hereby waives all rights to request
Court Ordered counseling under the Divorce Code.
Should a decree, judgment, or order of separation or divorce be obtained by either of the parties
in this or any other state, country or jurisdiction, each of the parties hereby consents and agrees that this
Agreement and all of its covenants shall not be affected in any way by any such separation or divorce; and
that nothing in any such decree, judgment, order, or further modification or revision thereof shall alter,
amend, or vary any term of this Agreement, whether or not either or both of the parties shall remarry (it
being understood by and between the parties hereto that this Agreement shall survive and shall not be
merged into any decree, judgment, or order of separation.) It is specifically agreed, however, that a copy
of this Agreement or the substance of the provIsions thereof, may be incorporated by reference into any
divorce, judgment, or decree. This incorporation, however, shall not be regarded as a merger, it being the
specific intent of the parties to permit this Agreement to survive any judgment and to be forever binding
and conclusive upon the parties.
4. DATE OF EXECUTION. The "date of execution" or "execution date" of this agreement shall
be defined as the d~te upon which it is executed by the parties if they have each executed the Agreement
on the same date. Otherwise, the "date of execution" or "execution date" of this Agreement shall be
defined as the date of execution by the party last executing this Agreement.
5. DISTRIBUTION DATE. The transfer of property, funds, and/or documents provided for herein
shall only take place on'the "distribution date" which shall be defined as the date of execution of this
Agreement unless otherwise specified herein.
6. WIFE'S DEBTS. Wife represents and warrants to Husband that since the separation she has
not and in t,.he future she will not contract or incur any debt or liability for which Husband or his estate
__might be responsible and shall indemnify Husband from any-and all claims or demands made against him
by reason of debts or obligations incurred ~y her.
7. HUSBANO'S DEBTS. Husband rep}esents and warrants to Wife that since the separation he
has not and in the future he will not contract or incur any debt or liability for which Wife or her estate might
be responsible and shall indemnify Wife from any and all claims or demands made against her by reason
of debts or obligations incurred by him.
;
.'
~,.- _._.o....uu.r~TANOING'J'OINT DESfs:'-- .0 .,0..
(a) Wife agrees that the following debts are her own personal responsibility and therefore agrees
to completely and finally pay on the following debts and obligations.
All loans and/or debts with Belco Community Credit Union, account #635740.
As well as all loans or debts under the Texaco Credit Card.
/'
/
(b) Husband agrees that the following debts are his own personal responsibility and therefore
agrees to completely and finally pay on the following debts and obligations.
All loans and/or debts under the Sunoco Card and Home Depot Account.
HUSBAND and WIFE agree that they will close out all joint credit card accounts and reapply for
new accounts in their own name.
9. MUTUAL RELEASE. Subject to the provisions of this Agreement, each party has released
and discharged, and by this Agreement does for himself or herself and his or her heirs, legal
representatives, executors, administrators, and assigns, release and discharge the other of and from all
causes of action, claims, rights, or demands whatsoever, in law or equity, which either of the parties sever
had or now has against the other, except any or all cause or causes of action for divorce and except any
or all causes of action of breach of any of the provisions of this Agreement.
10. DIVISION OF PERSONAL PROPERTY. Husband and Wife acknowledge that they have
divided their tangible personal property. Except as may otherwise be provided in this Agreement, Wife
agrees that all of the property of Husband or in his possession shall be the sole and separate property of
Husband; and Husband agrees that all of the property of Wife or in her possession shall be the sole and
separate property of Wife.
The parties shall exchange the following personal property pursuant to this agreement:
HUSBAND may obtain personal items such as clothing, tools, a various personal effects
from the marital residence at 1 Mountain View Drive, Mechanicsburg, Pa. 17055.
11. MU1:UAL WAIVER OF EMPLOYMENT BENEFITS. The parties agree to waive any and all
rights they have in and to each other's employment benefits, including but not limited to both parties
pensions, retirement plans, Incentive Savings Plans, and Tax Sheltered Annuities, except as relates to
Higher Education for the couple's children. (See below). The parties agree never to assume any claim to
such benefits of the oth~r at any time in the future.
12. MOTOR VEHICLES. With respect to the motor vehicles, owned by one or both of the
parties, they agree as follows:
(a) ,The TROOPER and PLYMOUTH shall be and remain the sole and exclusive property of Wife
,.- (b) The~JEEP CHEROKEE sl1all be and remain' the 'sole and exclusive property of Husband.
13. MARITAL HOME. WIFE holds title to the premises identified as 1 Mountain View Drive,
Mechanicsburg, Pa. 17055, Silver Spring Township. Cumberland County, 17055. The parties agree as
follows with respect to the marital residence:
(a) HUSBAND has delivered a warranty deed, conveying to WIFE all of his right, title and interest
in and to the marital residence. Therefore, WIFE is the sole owner of the marital residence and
has recorded the deed and may take any other action with respect thereto that she deems
appropriate.
.,
7 A """.,..."....'..._~~~.......~""_~:~~.~_,..>.,"'~:.,>,..i":I'<...<:...~.;'"
~.::~ <,0. '-, -:-: ~":'--"'.:~~~:"'-::'~'!':'T",,;,:n~_~,,:..:;<_~:00f"!,",~~~~,---_..~ __.
(b) As of the date of delivery of the deed, and without regard to when bills for such items are
incurred, received or due, WIFE shall be solely responsible for all past, present, and future costs
or liabilities associated with or attributable to maintaining the marital residence (except as
provided herein), including but not limited to, all real estate taxes, water and sewer rents, gas,
electric, and telephone service, homeowner's insurance, and gardening expenses and repairs,
and WIFE shall keep HUSBAND and his successors, assigns, heirs, executors, and
administrators indemnified and held harmless from any liability, cost or expense, including
attorney's fees, which are incurred in connection with such maintenance, costs, and expense.
(c) There is presently an outstanding mortgage against the martial residence in favor of National
City Mortgage of Dayton, Ohio, in the amount of approximately $140,000.00 under account
number 064743-2. Commencing on the date of this agreement, WIFE shall be solely responsible
for timely payments of all past, present, and future principal, interest and other fees under the
mortgage.
(d) WIFE shall indemnify and hold HUSBAND harmless from any liability, cost or expense, in
connection with any expense required to be made by WIFE including but not necessarily limited
to, the first mortgage, property taxes, and insurance with respect to aforesaid premises.
HUSBAND shall indemnify and hold WIFE harmless from any liability, cost, or expense in
connection with any expense required to be made by HUSBAND including but not necessarily
limited to, the second lien on the aforesaid premises.
14. ALIMONY PENDENTE LITE and LEGAL FEES. Each party hereby waives any right to
alimony pendente lite, and each party agrees to be responsible for his or her own legal fees and
expenses.
15. INCOME TAX RETURNS. Husband and wife represent to each other that to the best of their
knowledge all tax returns and other documents required to be filed with the Internal Revenue Service for
calendar years 1972 through 2000 have been filed and that no notices have been received from the
Internal Revenue Service which remain unresolved. Each party further represents to the other that to the
best of his or her knowledge, the information set forth in the joint tax return for these calendar years was
and remains accurate as relates to his or her sole income and acknowledges that the other party relied on
such representations in signing those returns. Therefore, if any deficiency in federal, state, or local
income taxes is-proposed, or any assessment of any such tax is made against the other party by reason
of his or her having joined in the filing of joint federal, state or local income tax returns, Husband and Wife
shall indemnify and hold harmless the other against and from any and all tax, interest, penalty, or expense
relating from any such tax deficiency, including reasonable counsel and accounting fees, and such tax,
interest, and penalties 9r expenses shall be paid solely and entirely by the responsible party as
determined to be attributable to that party on account of misrepresentation or failure to disclose relevant
information of income on the aforesaid joint returns.
For the year 2000, HUSBAND and WIFE plan on filing their taxes married joint. If any refund is
dlJe. and o~i~9... t~e refund will be split 50%/50% between the parties. For all subsequent years, each
party will file separately, and retaiiHheir respective refund amounts.
16. WAIVER OF ALIMONY. The parti~s herein acknowledge that by this Agreement, they have
respectively secured and maintained a substantial and adequate fund with which to provide for themselves
sufficient financial resources to provide for their comfort, maintenance, and support in the station of life to
which they are accustomed. Wife and Husband do hereby waive, release, and give up any rights they
may respectively have against the other for alimony, support, or maintenance. It shall be from the
execution of this Agreement the sole responsibility of each of the respective parties to sustain themselves
without seeking any support from the other party.
In furtherance of this paragraph, Wife agrees to withdraw any and all claims that she has
.....~~" 'II 'I' _'".,~~..~,..,~---
"---~--"'-~"4>"~'-"'~~18'~\lIY~t~M~'q,.o'[r:-, ~~''i<;:~_T_''.fiil~__;''1~& j., A"J 1111.. v
heretofore filed for alimony with the Court of Common Pleas of Cumberland County or any other Courts.
17. LEGAL AND PHYSICAL CUSTODY OF CHILDREN. The parties agree that WIFE will have
primary and legal physical custody of the children, Rebecca Green and Kati Green. However, HUSBAND
shall have liberal temporary physical custody according to a schedule to be agreed upon by the parties
which shall be consistent with the best interest and welfare of the said children.
18. HEALTH INSURANCE - CHILDREN. WIFE shall provide Blue Cross, Blue Shield, Major
Medical, and dental coverage or its equivalent for the benefit of the children. As secondary insurance,
WIFE shall also provide such coverage for the benefit of the children, for so long as it is available to her
through her employment. In the event one party is unable to provide the aforesaid coverage, the other
party shall obtain Blue Cross, Blue Shield, Major Medical, and dental coverage or its equivalent for the
benefit of the children for so long as it is available through employment. If neither party is able to maintain
said insurance through their respective employment, then the cost of said coverage shall be divided
equally by the parties. The parties agree that the twenty percent (20%) of the medical expenses which are
not covered by the medical coverage programs referred to above shall be paid by WIFE. The parties
further agree that any non-covered or extraordinary medical and/or dental expense, including orthodontia
shall be paid by WIFE.
This paragraph shall be made a part of any order of support referred to previously in this
agreement.
19. HIGHER EDUCATION. The parties have a Mutual Fund valued at approximately $20,000
that is jointly titled and is to be used for education purposes. HUSBAND also has a retirement fund,
valued at approximately $40.000. WIFE desires that her portion (50%) of this fund be used for education
purposes.
20. WAIVER OR MODIFICATION TO' BE IN WRITING. No modification or waiver of any of the
terms hereof shall be valid unless in writing and signed by both parties, and no waiver of any breach
hereof or default hereunder shall be deemed a waiver of any subsequent default of the same or similar
nature.
22. MUTUAL COOPERATION. Each party shall, at any time and from time to time hereafter,
take any and all.steps and execute, acknowledge, and deliver to the other party any and all further
instruments and/or documents that the other party may reasonably require for the purpose of giving full
force and effect to the provisions of this Agreement.
23. APPLICABLE LAW. The Agreement shall be construed in accordance with the laws of the
Commonwealth of Pennsylvania which are in effect as of the date of execution of this Agreement.
24. WAIVER OF CLAIMS AGAINST THE ESTATES: Except as herein otherwise provided, each
party may dispose of his or her property in any way, and each party hereby waives and relinquishes any
and all righ!s he or she may now have'bfhereafter acquire, under the present or future laws of any
jurisdiction, to sh.arein the .Pf9P_~rty ()r the estate of the other as a result of the marital relationship,
including without limitation, dower, curtesy,.statlitory allowance, widow's allowance, right-to-take intestacy,-._____ _.__...
right to take against the Will of the other, and ri~.ht to act as administrator or executor of the other's estate,
and each will, at the request of the other, execute, acknowledge. and deliver any and all instruments which
may be necessary or advisable to carry into effect this mutual waiver and relinquishment of all such
interests, rights, and claims. This agreement shall be binding and shall insure the benefit to the parties
hereto and their respective heirs, executors, administrators, successors, and assigns.
25. WARRANTY OF DISCLOSURE. The parties warrant and represent that they have made a
full disclosure of a/l their assets and their valuation prior to the execution of this Agreement. This
disclosure was in the form of an informal exchange or information by the parties' Attorneys and this
Agreement between the parties is based upon this disclosure.
11.... -,"'~
~ 11.~.,~"-,,),: 1..,'::~_~~~"li'~~t~":):M- .~ill -,_'f~~'-"Ji'lift:ll(LJ8ll\...J' " ~iJF'H1I' 1.
J _
26. INTEGRATION. This Agreement constitutes the entire understanding of the parties and
supersedes any and all prior agreements or negotiations between them. There are no representations or
warranties other than those expressly set forth herein.
27. OTHER DOCUMENTATION. Wife and Husband agree that they will cooperate and execute
any and all written instruments, or such other writings as may be necessary or desirable for the proper
effectuation of this Agreement.
28. NO WAIVER OF DEFAUL T.This Agreement shall remain in full force and effect unless and
until terminated under and pursuant to the terms of this Agreement. The failure of either party to insist
upon strict performance of any of the provisions of this Agreement shall in no way affect the right of such
party hereafter to enforce the same, nor shall the waiver of any default or breach of any provision hereof
by construed as a waiver of any subsequent default or breach of the same or similar nature, not shall it be
construed as a waiver or strict performance of any other obligations herein.
29.. SEVERABILITY. If any term, condition, clause, or provision of this Agreement shall be
determined or declared to be void or invalid in law or otherwise, then only that term, condition, clause, or
provisions shall be stricken from this Agreement; and in all other respects, this Agreement shall be valid
and continue in full force, effect, and operation. Likewise, the failure of any party to meet his or her
obligations under anyone or more of the paragraphs herein, with the exception of the satisfaction of the
conditions precedent, shall in no way avoid or alter the remaining obligations of the parties.
30. BREACH. If either party breaches any provisions of this agreement, the other party shall
have the right, at his or her election, to sue for damages for such breach, or seek other remedies or relief
as may be available to him or her, and the party breaching this contract should be responsible for payment
of legal fees and costs incurred by the other in enforcing their rights under this agreement.
IN WITNESS WHEREOF, the parties. have hereunto set their hands and seals the day and year
first above written:
WITNESS:
~tbt;l.A-;
CATHI JO GR~~
Date:
COMMONWEALTH O,F PENNSYLVANIA )
):ss
COUNTY OF CUMBERLAND )
On this, thd?~ay Of)J~ ,2000, before me, the undersigned officer,
personally. appeared CATHI JO GREEN known to me, (or satisfactorily proven) to be the person whose
name is subscribed to the within instrument, and acknowledged that he/she executed the same for the
purposes therein contained.
IN WITNESS WHEREOF, I hereunt~ s~t my hand and official seal.
otary~~ .. . 3' -.,.,.. .., ~--
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My commisslon'expires::" ........ :.~.:,'.'
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&. ....-:._....._ ~,"l"O"'- T~~~_
/:.L t:/f-
RICHARD F. GREEN
~f,aJ%o
W' ess
Date:
COMMONWEALTH OF PENNSYLVANIA )
):ss
COUNTY OF CUMBERLAND )
On this, thf)g-fl, day of N/J~2000. before me, the undersigned officer,
personally appeared RICHARD F. GREEN known.to me, (or satisfactorify proven) to be the person whose
name is subscribed to the within instrument, and acknowledged that he/she executed the same for the
purposes therein contained.
IN WITNESS WHEREOF, I hereunto set my hand and official
S .
. , 0 ary u: )~T!'t~~!P.L S~..Al
~.. .~.:'.' ~'..!~~ t' l;,:~~ :', "-.r';. t..:>:~t~:r'/ P~!b~c
~My G<;>mriiission.'expj(es:'-~:. C:,'.l;;t;j
~~~~~:;::;':~:~~i1tl ~~r~t. 0, 2iJC4
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COMMONWEALTH OF PENNSYLVANIA
PUBLIC SCHOOL EMPLOYEES' RETIREMENT SYSTEM 41 i \1 e-
Toll-Free. 1-888-773-7748
(l-888-PSERS4Ul
Local.717-787-8540
Web Address: www.psers.state.pa.us
AUGUST 14, 2000
Mailing Address
PO Box 125
Harrisburg P A 17108-0125
Building Location
5 North 5th Street
Harrisburg PA
-0
J
S.S. # 201-40-7517
RET TYPE - EARLY
Termination Date. June 6, 2000
Retirement Date - June 7, 2000
RICHARD F GREEN
1 MOUNTAIN VIEW DR
MECHANICSBURG PA 17050
INITIAL RETIREIVIENT BENEFIT (ESTIMATED)
Your retirement has been calculated based on your option selection and the latest salaries
and service on file in the Public School Employees' Retirement System (PSERS). The terms
of your retirement plan will be binding unless you file the enclosed "Intent to Change the
Terms of the Retirement Plan (PSRS-1242)."
You selected the Maximum Single Life Annuity and decided to withdraw your total
contributions and interest.
.~~
Beginning September.2?, 2000, your estimated monthly benefit w~e ) ~U~.2~ '
In 7 to 10 business days two payments will be issued on your benaif. The payment for
$40,000.00 (outlined below) will be directly rolled over to HORACE MANN LIFE INS CO.
$ 40,000.00
+ .00
$ 40,000,00
Partial Lump Sum
Installment Interest
Total Benefit to be Directly Rolled Over
In addition a payment for $ 11,600.80 (outlined below) will be sent to you.
+
+
+
$ 1,966.32
10,650.19
332.24
.00
1,347,95
$11,600,80
Initial Monthly Payment (06/07/2000 to 08/31/2000)
Partial Lump-Sum Payment
Installment Interest
Tax Deducted from Initial Monthly Payment
Tax Deducted from Partial Lump-SumlInterest
Net Check
A 20 percent federal withholding tax has been deducted from the taxable portion of your
payment. You may still elect to roll over to an IRA or another employer plan that accepts
your rollover, any or all of the $ 6,739,76 taxable portion, within 60 days of the receipt of
Dated Material Enclosed
Please read reverse side for more information
EXHIBIT
lllllllllllllllllll~ 1111111111 1111111111111
IIIII~ IIIII~ 11111~ 11~11l1l1 ~1111I1111111I1I11I1I11I11II111/111I11! 11111111111111111111111
.OlOOO201407517127*
I
])
SII14.PPR.I-I27 "S134 01.
ANNUITANT INFORMATION
,v:r or ,ayorN1me \ \j1}1 -) , -J-
lnVI.t.J f~. ~"C\' C\ ( i f- ,~( L, V dt
Street A,ddressC-- I f I l,ty ,
(IJ 7Y~_ "C\~ 11./t: .'tAfl'l~fi( 11~,.J/f>1tllq
State Zip Birthdate
o "- 5 Mo. I Day
Owner (It other th,m A.nnuitant)
~NUITY APPLICATION ('7\ /, (. "'" -
, /J / L)~ \) L'J ~/Lt\:,yCJD
-
Social Security .
1\)1: YD :1517
M~ (~~N l'('~ bl.\,~(;
Telephone
\)~. ( ) i. 7-5 7~
Is the annuity now applied for to replace any life insur-
ance or an,:!uj.ties in force ,in this or any other company?
DYES MNO (If yes, gIve Name of Company or Companies)
PLAN INFORMATION
TAX STATUS: _~-......
~Tax Deferred [1.ti(E' 4~3.!Ell--'
OIRAjj '-1'6 -l~J
o Spousal IRA " \;
o Master Pension Plan [I.R.C. 401 (a)]
o SEP-IRA
OHR-10 (Keogh)
o Non - Qualified
o Other
CJ FIXED ACCOUNT FIXED AND VARIABLE ACCOUNT
o Group 0 Individual
o Flexible Premium. . , . . .. Initial Renewal Period_Years
o Single Premium. . . . . . . . Initial Renewal Period_Years
o Other
HOME OFFICE USE ONLY: (Not Applicable in PA & W. VA)
Horace mann life Insurance [ompanlf
HOME OFFICE - ,I HORACE MANN PLAZA
SPRINGFIELD, ILLINOIS 627,150001
Year
St reet Address
City
State
Z,p
Social Security
I
I
Birthdate
Mo ! Day
Relationship to Annuitant
Year
BILLING INFORMATION
I Years Maturitv Date
Year Payable Mo.: Day
I
Level Mode Premo InitialPrem, : No. Pays Subsequent Prem 'N P
$ J DC'; . iJ I.> j 1 fo . l 0 ays
Total FlTst Year Premo List Bdl NUlT'ber Month of FlTst Reduction
$ 1 co _ 00 37- I~L 'l- 9~
aUST BILL Dc.o.M. ODIRECT OSINGLE PREM.
0,/,2 0,/12 0 Annually
0'1/10 0,/10 0 Semiannually
o 1/9 . 0 1/9 0 Quarterly
~ I i 1... (" 0 Monthly
Effective Date
Mo. I Dav
I
I
Yea"
$
BENEFICIARY INFORMATION
Primary Beneficiary: Relationship
.(: Etl b ; _ _J ~ _ _ ,_ ~ ~ t ~_ _ _ _ _ _ _'~/~ ~) J>_ _ _
Successor Beneficiary: Relationship
COMMENTS AND SPECIAL REQUESTS:
THE AMOUNT OF ANNUITY PAYMENTS AND CASH VALUE PAYABLE FROM THE VARIABLE ANNUITY SEPARATE
ACCOUNT UNDER THE CONTRACT ISSUED PURSUANT TO THIS APPLICATION ARE VARIABLE AND ARE NOT
GUARANTEED BUT WILL INCREASE OR DECREASE BASED UPON THE INVESTMENT EXPERIENCE OF THE SEPARATE
ACCOUNT.
It is hereby stated that",each of t~e statements and answers given above ar~ full, comp'e~7\d true to the best of
my knowled~iI1A V . . u, fJ 11 I. ..,1A /j!J 9
Dated at: I I V Ul.-cJ~(..d}.oI<A-'Uj r if thiS . J l . day of ~ YA}-1u..o..-u.j ,19~.
rf i ;r<' 1~.j~1 F )~ cf
Owner's Signature (If other than Annuitant) Annui'tant's Signature
S,. ':"~ture of Piilrenlif AJ;tnU,ita~tiis under age 15.
'\ \ '\ .....a \ ' ~ -, . t"/ r.
\~) V'V\.A\YV ' )' ArvfiJ 7. ,,) t l' '-1
Witness or Licensed Agent's Signature, State and Agent Code
IL-A lD9A 1
Employer Represeitta
EXHIBIT
Title
I
~
PART 1
SUITABILITY QUESTIONNAIRE
(Required 'In All Combination Contracts)
Horace mann life Insurance. [ompan4
HOME OFFICE -. r HORACS MANN PLAZA
SPRINGFiElD ILLINOIS 627150001
TAX DEFERRED ANNUITY [I.R.C. 403(b)] INFORMATION
(Required on all Tax Deferred Annuity Applications)
SOURCE OF PURCHASE PAYMENTS:
~ Employee - Contributions through salary reduction agreement:
Has salary reduction agreement been completed?
If no, why not?
t&t Yes
o No
o Employer - Contributions as employee benefit:
$
$
-~------------------------------------------------------------------------------------------------------------------------------------
EXCLUSION ALLOWANCE INFORMATION
1. State (or city, district, etc.) retirement system.
2. Contract salary for tax year.
3. Years of service completed with current employer through prior calendar year.
4. Years of past service (all districts) worked while covered by current retirement system
in which the annuitant participates.
5. Total TDA contributions to date by current employer to all companies.
6. Current annual TDA contributions to all companies.
7. Annuitant's contribution to retirement benefit of state retirement system for public
school employees from taxable income as a percent of contract salary.
Annuitant's Signature: X
.~
1. PA
2. $ YO
3. 1[1
4. J~
5. $ .3000
6. $ ~fnoo
\ io
r.".
7. $ ~y
AGENT'S REPORT
Based on the information available to you, do~ou.believe the annuity as applied for to be a suitable investment for
the proposed Annuitant? ~ Yes . 0 No .
To the best of your knowledge will this annuity now applied for change or replace any life insurance or annuities
now in forc~~th thi~,or any other compa'(~? 0 Yes ~ No
~,.. ) lPVJJ 6 (f/4~ 3 7
-- , Agent's Signature
Signed:
State Code
Dated:
d - 10 - g 3
IL-A 109A2
3~9'9
Agent Code
,
PART 2
(!)
IdraE! mann.
Insuring Ameflca'. EducalloNl Community
.1tb
Rellremer.t Annuilies and
Life, AulD, Homeowners and
Group Insurance
The Horace Mann Companies
1 Horace Mann Plaza
Springfield, illinois 62715-0001
(217) 789.2500
October 4, 200 1
Cathi Jo Green
1 Mountain View Dr.
Mechanicsburg, P A 17050
Subject: Annuity contracts #0570358080 and 0506405200
Claim #0 1 04040
New Supplemental Contract S20279
Dear Ms. Green:
Thank you for choosing a Horace Mann settlement option for the proceeds of your husband's
annuity contracts.
So you can begin receiving payments according to the retirement income option you selected,
your husband's annuity contracts #0570358080 and #0506405200 have been terminated and
replaced with the Annuity Income Statement of Benefits enclosed.
Annuity contract #0570358080 had a total cash value of $40,000.00 to which we added interest
of$III.91. Annuity contract #0506405200 had a total cash value of $48,057.98 to which we
added interest of $134.45.
Currently this contract is earning 5 percent interest annually.
We will electronically deposit your first installment into your checking account at PNC Bank in
approximately three days. Subsequent payments- will be deposited in your bank account by
electronic fund transfer on the first working day of the month your payment is due. Assuming
that the current interest rate remains the same and no withdrawals are made, your final payment
of$928.03 will be issued September 1,2011.
In addition, as we understand tax regulations, you must report these payments to the Internal
Revenue Service as taxable income for the year you receive them.
To be sure your payments reach you without delay, notify us immediately of any address or bank
changes.
EXHIBIT
I V
www.horacemann.com
HOrc1[! mann..
@
Insuring America's Educational Community
Annuity Income Statement of Benefits
Annuitant: Cathi Jo Green
Annuitant Birth Date: 09124/1951
Issue Age/Sex: 50/F
Contract Number:
Annuity Payout Effective Date:
Plan Code:
Payout Option:
Contract Value:
Payment Frequency:
Number of Payments:
Guaranteed Amount:
Excess Interest:
Current Payment:
Cost Basis:
Exclusion Percentage: .
Beneficiary Information
NAME
ALLOCATION
SSN
Retirement Annuities and
Ute, Auto, Homeowners and
Group Insurance
The Horace Mann Companies
1 Horace Mann Plaza
Springfield, Illinois 62715-0001
(217) 789-2500
S20279
1 % 1/200 1
34309
~
88,304.34 \
120
$888.13
$39.90
$928.03
$.00
.0000
The contract value will be retained by the Company. Annuity income payments will be made on the
annuity payout effective date and continue until 120 such payments have been made.
The current payment will be the guaranteed amount plus excess interest. The Company reserves the right
to adjust the payments, however the current payment will never be less than the guaranteed amount.
Partial withdrawals will reduce the contract value as well as the future paymenfs. Withdrawals are
subject to the provisions of the original contract. Penalties may apply.
In the event of the death of the Annuitant, the remaining payments will be made to the named
beneficiary(ies) at the time of death. If no beneficiary survives the Annuitant, the commuted value of
the remaining payments will be paid to the Executor or the Administrator of the Annuitant's estate.
We will send an annual statement to you on the payout anniversary each year.
EXHIBIT
I G~
www.horacemann.com
Page 2
If you have any questions or need assistance, please let us know by calling our toll-free number,
1-800-999-1030. Refer to your new supplemental contract #820279. We will be glad to help
you.
Sincerely,
Samantha Utterback
Annuity Benefits Specialist I
Annuity Benefits and Claims
cc: Donald Fronk #3689
717-697-5976
Bank account information for Electronic Fund Transfer (EFT)
Please complete the following if you wish to have your payment sent directly to your bank electronically for deposit.
Include a voided blank check or savings deposit slip to help us route your payments to your bank (if available through
yuu.. b('f ~:).
Bank name _p N L 6 Q..".J k
Routing # b.~1 ~.z 1,1 Z e
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Street I City I State
Date of birth q - ; LJ - 5 I Social Security # J... 0 J - L/ 1..- 2. q J. 7 Telephone #(lli)
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Full name/address SS# Birth date Relationship to insured
Annuitant's signature
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Agent name
*Beneficiary(ies) must be identified by name.
** Note: If contract was issued in Arizona, California, Idaho, Louisiana, Nevada, New Mexico,
Texas, Washington, or Wisconsin and the owner was married at the time of issue, the spouse's
signature is required.
Date f' '" 7-() I
Date
Agent #
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Additional information
Horace Mann Life Insurance Company, located at P.O. Box 4657, Springfield, III. 62708-4657, underwrites the Annuity
Alternatives Contracts which are offered by Horace Mann Investors, Inc.
Horace mann~
Insuring America's Educational Community
WWW.horacemann.com
www.reacheverychild.com
IA-004046 (2/00)
1 Mountain View Drive
Mechanicsburg, P A 17050
August 3, 2001
To Whom it May Concern,
,~ .. ,',:
Request for retirement income/settlement options
I, C u-t~,' J c &~ee;J
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, request the following action(s) under contract #
C~ below to indicate the option(s) you want. If you are requesting a combination of options, ph::c:.~e ..
in<iija~hd ci:ilr amount or percentage on the reverse side under Additional Information. Proof of age is required
for any lifetime income options. G \ 3 ~H' \ :\'3 .
Fixed lifetime income options'l.OU\ AU Other fixed income options
o Life only RECE\VEO CC&R 0 Interest Income
o Life with a Period Certain ;gf Fixed Period
Period Certain years (10, 15, 20) Period requested
o Joint and Survivor 0 Fixed Amount
_50% _66.67% _100% Amount requested $
Joint payee:
Name
Birth date
Social Security #
10
years
Sex
If you have money in the variable account and wish to choose a fixed option, the transfer of your value to the fixed
account and change in allocation to the fixed account will occur on the date we receive this form, unless otherwise
indicated.
Variable lifetime income options (indicate amount, or shares)
o Life only
o Life with a Period Certain
Period Certain: years (10,15, 20)
o Joint and Survivor
to HM Equity Fund
to HM Balanced Fund
to HM Income Fund
50%
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Name
Birth date
Social Security #
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If you have money in the fixed account and wish to choose a variable option, the transfer of your value to the variable
accounts indicated and change in allocation to the variable accounts will occur on the date we receive this form, unless
otherwise indicated.
Horace Mann requires that all retirement income/settlement options begin on the first of each month. (If a request is
received after the first, the effective date will become the first of the fOllowing month.) Please indicate the date you
would like your option to begin and the mode of payment.
Date option is to be effective q ~ I - 0 1 .
Mode of payment: B! monthly 0 quarterly 0 semi-annual 0 annual
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State tax withholding information
You must elect whether vou want state taxes withheld
Federal tax withholding information
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1 Mountain View Drive
Mechanicsburg, P A 17050
August 3, 2001
To Whom it May Concern,
When Richard F. Green designated a beneficiary of his tax shelter and retirement roll
over, upon his death the intended beneficiary was to be myself, Cathi Green, even upon
separation or divorce.
Thank You,
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Cathi Green
EXHIBIT
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COMMONWEAL TH OF PENNSYL VANIA
COUNTY OF DAUPHIN
: ss.
On this, the ,;/fJ -r:L day of ~ ' 2003 before me, the
undersigned, personally appeared Cathi Jo Green, w acknowledged herself to be the Executrix,
a Beneficiary, and Residuary Legatee ofthe Estate of Richard Francis Green, Deceased, executed
the foregoing instrument for the purposes therein contained.
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
~
NOTARyp~r
NotaIfal Seal
l&>~~t=~
- ~~\__ Feb. 10, 2!:1J1
. .......... Of NolaItes
COMMONWEAL TH OF PENNSYL VANIA
COUNTY OF 1) fl Ll P 1'/ I /,'
: ss.
On this, the d~~ day of ~ ' 2003 before me, the
undersigned, personally appeared Rebecca A. Gr n, who acknowledged herself to be a
Beneficiary and Residuary Legatee of the Estate of Richard Francis Green, Deceased, executed
the foregoing instrument for the purposes therein contained.
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
G .~
~TA Y u~
NotaIiaI Seal
Connie L. Hardy, Notary Public
aty Of Harrisburg, Dauphin County
My Commission Expires Feb. 10, 200l
Member, PennayIvania Association Of NaarIes
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF ~4V(f'H-It\'
: ss.
On this, the c::1 ~--ct.. day of ~ ' 2003 before me, the
undersigned, personally appeared Kati L. Green, wh acknowledged herself to be a Beneficiary
and Residuary Legatee ofthe Estate of Richard Francis Green, Deceased, executed the foregoing
instrument for the purposes therein contained.
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
~~~I
Notarial Seal
CornIe L. Hardy, NotaJy Pu/:jc
CIty Of HMIsburg, Oauphil Quty
My 00mmIssi0t, Expires Feb. 10, 'J!XJT
Member. Fema)'Ivllnia AssociaIIon OfNcDfes
f
---
BEFORE THE REGISTER OF WILLS
CUMBERLAND COUNTY, PENNSYLVANIA
INRE:
ESTATE OF
RICHARD F. GREEN
Name of Decedent: Richard F. Green
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
: ORPHANS' COURT DIVISION
: ESTATE NO. 2001-00476
: SOCIAL SECURITY #201-42-7517
CERTIFICATION OF NOTICE
UNDER RULE 5.6(a)
Date of Death: April 24, 2001
Will No.: Adm. No.: 2001-00476
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 beneficiaries of the above-captioned estate on
August 22, 2001.
Rebecca A. Green
1 Mountain View Drive
Mechanicsburg, P A 17050
Kati Lynne Green
c/o Cathi Jo Green, Guardian ofKati Green,
a Minor
1 Mountain View Drive
Mechanicsburg, P A 17050
BOSWELL, TINTNER, PICCOLA & WICKERSHAM
By:
Capacity:
Dated: August 22, 2001
~L-
ef y R. Boswell, Esquire
Supreme Court I.D. #25444
315 North Front Street
P. O. Box 741
Harrisburg, PA 17108-0741
(717) 236-9377
_ Personal Representative
_X_ Counsel for personal representative
f
.......-
IMPORT ANT NOTICE
NOTICE OF ESTATE ADMINISTRATION
THIS NOTICE DOES NOT MEAN THAT YOU
WILL RECEIVE ANY MONEY OR PROPERTY
FROM THIS ESTATE OR OTHERWISE.
Whether you will receive any money or property will be determined wholly or partly by the
decedent's will. If the decedent died without a will, whether you will receive any money or property
will be determined by the intestacy laws of Pennsylvania.
BEFORE THE REGISTER OF WILLS
CUMBERLAND COUNTY, PENNSYLVANIA
INRE:
ESTATE OF
RICHARD F. GREEN
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
: ORPHANS' COURT DIVISION
: ESTATE NO. 2001-00476
: SOCIAL SECURITY #201-40-751].
NOTICE OF BENEFICIAL INTEREST IN EST ATE
PURSUANT TO RULE 5.6
TO: Rebecca A. Green
1 Mountain View Drive
Mechanicsburg, P A 17050
Please take notice of the death of decedent and the grant of letters to the personal
representative(s) named below.
The Decedent, Richard F. Green, died on the 24th day of April, at Cumberland County,
Pennsylvania.
The Decedent died testate.
The personal representative of the Decedent is Cathi Jo Green, Executrix, 1 Mountain View
Drive, Mechanicsburg, PA 17050, telephone no. (717) 697-5976.
The will has been filed with the Office of the Register of Wills of Cumberland County,
Cumberland County Courthouse, 1 Courthouse Square, Carlisle, Pennsylvania 17013-3387.
Cumberland County - Register Of wills
Hanover and High Street
Carlisle, PA 17013
phone: (717) 240 - 6345
Date: 3/10/2003
CATHI JO GREEN
1 MOUNTAINVIEW DRIVE
MECHANICSBURG, PA 17050
RE: Estate of GREEN RICHARD FRANCIS
File Number: 2001-00476
Dear Sir/Madam:
It has come to my attention that you have not filed the Status
Report by Personal Representative (Rule 6.12) in the above captioned
estate.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO.
103 SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after
July 1, 1992, the personal representative or his counsel, within two
(2) years of the decedent's death, shall file with the Register of
wills a Status Report of completed or uncompleted administration.
This filing will become delinquent on: 4/24/2003
Your prompt attention to this matter will be appreciated.
Thank You.
Sincerely,
DONNA M. OTTO
DEPUTY REGISTER OF WILLS
cc: ./ File
Counsel
Judge
/
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
ESTATE OF
RICHARD F GREEN
, Deceased
No. 20-01-476
of 2001
To the Clerk of the Orphans' Court:
Enter the claim of G.APITAL ONE
Acct. 5291071859609594
In the amount of
$561 .44
, against the above entitled estate.
The decedent, who resided at 441 N RIVER ST, , LEMOYNE PA 17043
died on
04/24/2001
. Written notice of said claim was given
to CA THI JO GREEN
,if known to claimant, at
(Personal Representative or counsel)
1 MOUNTAINVIEW DR, MECHANICSBURG, PA 17050
on
July 8, 2001
(Date)
(Claimant)
Tr
Address:
5330 Eas.t Main Str_~t, Suite 200
Columbus, Ohio 43213
Claimant's Counsel
Address
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Citicorp Credit Services, Inc.
A Subsidiary of CitiGroup
Kansas City Regional Center
7920 N.W. 110th Street
Kansas City, MO 64153
~/-- 6/--!J 7k~
July 24,2001
CUMBERLAND COUNTY COURTHOUSE
1 COURTHOUSE SQUARE
ROOM 102
CARLISLE, PA 17013-3387
RE: The Estate of RICHARD GREEN
File Number: 212001476
Dear Sir/Madam:
Please find enclosed our claim against the above-mentioned estate. Please return a "FILED" stamped copy in the
enclosed envelope.
Payments should be sent to:
Citibank
P.O. Box 8001
South Hackensack, NJ 07606
Please reference the account number on the check. Thank you for your attention to this matter.
Very truly yours,
Tammy Anzelone
Manager
MB/mm
0274c (Court)
Enclosure
07/2412001-145
c
IN THE COURT OF COMMON PLEAS, CUMBERLAND
COUNTY
PENNSYLVANIA
ORPHANS' COURT DIVISION
ESTATE OF
RICHARD GREEN
Register's # 212001476
Deceased
CLAIM
To the Clerk of the Orphans' Court Division:
Index and make proper entry in your official records of the
claim of Citibank(South Dakota)N.A. in the amount of $355.48
against the estate of the above-named decedent. This claim is
filed under Section 3532 (b) (2) PEF Code, 20 Pa. C.S. ss. 3532
(b) (2).
The said decedent, whose last known residence was at
RIVERST APT 2 LEMOYNE PA 170431123
441 N
written notice of this claim was given to
Executor, 1 MOUNTAINVIEW DR, MECHINICBURG, PA 170500000
CATHIE JO GREEN,
on July 24,2001.
(C imant)
Tammy Anzelone, anager of Citicorp Credit Services,
Inc. under limited power of attorney for Citibank (South
Dakota) N .A.
7930 NW 110 Street,
Kansas City, MO 64153
(Claimant's Address)
07/24/2001.145
Acct. #5424180426689862
l 4"355. ifg J
OS/21/01 $373.70 $20.00
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SD 00 Al 1 1200 MC 0018
MC 4
CITIBANK
P.O. BOX 8118
S HACKENSACK, NJ
USA 07606-8118
RICHARD GREEN
441 N RIVER ST APT 2
lEMOYNE PA
17043-1123
For Customer Service call or write
Citibank Platinum Select
1-800-950-5114
BOX 6500
SIOUX FAllS, SD
57117
Account Number
5424 1804 2668 9862
Payment must be received
Statement Date Total Credit Line Cash Advance Limit
04/26/01 $7000 $3500
REDIT PROTECTOR FEE
ERIZON TElEPRODUCTS
NI MARTS #4255
INE & SPIRITS 2108
INE & SPIRITS 2108
ERAlD STEVENS - F-FTD
ATIONAl FlORA
ERSHEYPARK ARENA TICK
ERSONAl GAINS
INE & SPIRITS 6708
07/07/01
00: 11: 32
For billing inquiries write to
this address: calling will not
preserve your rights.
Amount TIC
00
6354
1338
11 7
1822
3657
5495
8700
6995
1822
1 time on OS/21/01
Available Credit Line Available Cash line
$6626 $3500
Bin#OfMer# A Sic
4 0000
1A4812US 6171
lA554lUS 2596
1A5921US 5828
1A5921US 5828
lA5992US 2454
1A5992US 2950
1A5969US 1873
1N5969USA2019
lA592lUS 5828
0000000000
78483301088
23425961092
70446411094
70446411095
88424541100
78429501103
88418731107
75414911110
70446411115
Amount Due
- Credits + Finance + Late = Balance Pur Min Due
Charges Charges Adv Mjn DUe
AmountoCL
37370 Fees
Past Due
37370 MinAmtDue 2000
8002771060 PA
WEST FAIRVIE PA
ENOlA PA
ENOlA PA
lEBANON PA
541 776 2434 OR
(717)534-3300 PA
800-889-7835 CT
NEW CUMBERlAN PA
P
i
notice for important
CANCER SOCIETY RELAY FOR lIFE IS YOUR
lEBRATE CANCER SURVIVORSHIP AND HONOR
F lOVED ONES. WE INVITE EVERY COMMUNITY
THER FOR THIS CELEBRATION OF LIFE. CAll
45 OR VISIT WWW.CANCER.ORG ANYTIME.
Ace nt Summar
Previous
Balance
+ Purchases
& Advances
- Payments
PUfcll<l5e5
Advances
Toto'll
Rate Summary
PURCHASES ADVANCES
Nlllllberofdays
this Billing Period
29
Balance subject to
Finance Charge
Periodic Rate
Nominal Annual
Percentage Rate
Annual Percentage Rate
.03695Y.
13.490Y.
13.490Y.
.05476Y.
19.990Y.
19.990Y.
$'373.10
- Jg.~~ ~
-
.- -$ 365.4-8
STATUS REPORT UNDER RULE 6.12
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(jh
Name of Decedent: Richard F. Green
Date of Death: April 24, 2001
Will No.: Admin. No.: 2001-00476
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 0 No [!l
2. If the answer is No, state when the personal representative reasonably believes
that the administration will be complete: September 30 r 2003
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 0
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 0 NoD
c. Copies ofreceipts, releases, joinders and approval of formal or
informal accounts may be filed with the Clerk of the Orphans' Court
and may be attached to this report.
Date: March 26, 2003 ~ ~~ J~
Signat~ ~
Jeffrey R. Boswellr Esquire
Name
315 N. Front Street
P. _ o. Box 741
Harrisburg, PA 17108-0741
Address
(717) 236-9377
Telephone No.
Capacity: 0 Personal Representative
l!l Counsel for personal representative
Register of Wills of Cumberland County, Pennsylvania
INVENTORY
Estate of
GREEN, RICHARD F.
No.
~~O~ _~rz lP__ __
also known as
Date of Death 4/24/2001
, Deceased
Social Security No. 201-40-7517
Cathi Jo Green
- ..---------- --.....-.------- .._---~-~--- ~ ------
The Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following Inventory
include all of the personal assets wherever situate and all of the real estate located in the Commonwealth of Pennsylvania
of said Decedent, that the valuation placed opposite each item of said Inventory represents its fair value as of the date of
the Decedent's death, and that the Decedent owned no real estate outside of the Commonwealth of Pennsylvania except
that which appears in a memorandum at the end of this Inventory. I/We verify that the statements made in this Inventory
are true and correct. I/We understand that false statements herein are made subject to the penalties of 18 Pa. C. S.
Section 4904 relating to unsworn falsification to authorities.
Attorney:
Jeffrey R. Boswell
- - ----
Personal Representa~. I . /.
Signature: ~__
Cathi Jo Green
\.D. No.:
25444
Signature:
Signature:
Address:
315 N. Front Street
P. O. Box 741
Address: 1 Mountain View Drive
Mechanicsburg, P A 17050
U<>rrid'll1Ta P A 171OSL0741
Dated:
1/7 - (g}l7-S9~___
~.... )-&-03
Telephone: 717/236-9377 Telephone:
Personal Property
PNC Account No. 50 0324 4409
2,864.36
Horace Mann Insurance (refund)
167.60
Provident Life Insurance (refund)
20.10
Horace Mann Insurance Company (car repair claim check)
703.11
1997 Jeep Cherokee
7,625.00
PA-40-2001 Income Tax Refund
129.00
1040-2001 Income Tax Refund
136.31
Blue Cross/Blue Shield refunds
79.50
Total Personal Property
$11,724.98
(Attach additional sheets if necessary)
Total Personal Property and Real Estate
$11,724.98
Register of Wills of Cumberland County, Pennsylvania
INVENTORY
continued
also known as
Estate of GREEN, RICHARD F.
No. 21 - 01
Date of Death 4/24/2001
Social Security No. 201-40-7517
. Deceased
Real Estate
NONE
Total Real Estate
2
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
BOSWELL JEFFREY R ESQUIRE
31 5 N FRONT STREET
PO BOX 741
HARRISBURG, PA 17108-0741
-------- fold
ESTATE INFORMATION: SSN: 201-40-7517
FILE NUMBER: 2101-0476
DECEDENT NAME: GREEN RICHARD FRANCIS
DATE OF PAYMENT: 08/28/2003
POSTMARK DATE: 00/00/0000
COUNTY: CUMBERLAND
DATE OF DEATH: 04/24/2001
NO. CD 002950
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $26.49
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
$26.49
REMARKS: JEFFREY R BOSWELL
C/O JEFFREY R BOSWELL ESQUIRE
CHECK# 21799
SEAL
INITIALS: VZ
RECEIVED BY:
REGISTER OF WILLS
DONNA M. OTTO
DEPUTY REGISTER OF WILLS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128.0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
BOSWELL JEFFREY R ESQUIRE
31 5 N FRONT STREET
PO BOX 741
HARRISBURG, PA 17108-0741
____n__ fold
EST A TE INFORMATION: SSN: 201-40-7517
FILE NUMBER: 2101-0476
DECEDENT NAME: GREEN RICHARD FRANCIS
DATE OF PAYMENT: 08/28/2003
POSTMARK DATE: 00/00/0000
COUNTY: CUMBERLAND
DATE OF DEATH: 04/24/2001
NO. CD 002949
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $298.79
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
REMARKS: CA THI JO GREEN C/O
JEFFREY R BOSWELL ESQUIRE
CHECK# 116
SEAL
INITIALS: VZ
RECEIVED BY:
REGISTER OF WILLS
$298.79
DONNA M. OTTO
DEPUTY REGISTER OF WILLS
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,
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INHERITANCE TAX RETURN
RESIDENT DECEDENT
N/A,
18I 1. Original Return 0 2. Supplemental Return
D 4. Limited Estate 0 4a. Future Interest Compromise (date of death
after 12-12-82)
o 6. Decedent Died Testate (Attach copy 0 7. Decedent Maintained a Living Trust (Attach
, of Will) copy of Trust)
~. 0 9. .Uti.gatloo Pmceeds R..e.. ce. Ived 0.' o. .. ~f~~-~~' ;:~vte~.9._.;.) redit (dato of d,ath.. between D 11. Elect. 100 to tax "der s.. ec. 9113(A) (All"h Soh 0)
THISSECTION MUST BE COMP~ETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTE[) TO:
A;:ff:ey ~- Bos~ell - . - - - FMPlETE MAILING ADD-RE..----- - .
tIRMNAME(lfapPI-i~ble} -, 315 N. Front Street
Boswell Tintner Piccola Wickersham P. O. Box 741
. ELEPHONENUMBER _I Harrisburg, PA 17108-0741
717/236-9377
~"_7_"_'__
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT,260601
HARRISBURG. PA 17128-0601
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I DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITiAL)
I ~~:~~A~~~~~:A~;mDATE OF BIRTH (MM-DD-YEAR)
i 04/24/2001 02/24/1951
'(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST AND MIDDLE INITIAL)
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1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation. Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
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5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6, Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule f)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus line 11)
i FILE NUMBER
21 01
COUNTY cqpJ:' YEAR
SOCIAL SECURITY NUMBER
0476
I\J!JMBER
201-40-7517
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
0-3
o
Remainder Return (date of death prior to 12-13-82)
5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
(1)
(2)
(3)
(4)
(5)
----------...-
(6)
(7)
(9)
(10)
- c:1-
-0-
'-.' ~.
None
None
i'J
None
11,724.98
1,930.62
-0-
-~>.
(8)
13,655.60
3,822.19
3,193.53
(11)
7,015.72
6,639.88
(12)
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
(13)
(14)
6,639.88
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
298.79
298.79
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
20. 0
>> BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH <<
Copyright 2000 form software only The Lackner Group, Inc.
15.Amount of Line 14 taxable at the spousal tax rate, x .00 (15)
or transfers under Sec. 9116(a)(1.2)
z 6,639.88 .045 (16)
0 16.Amount of Line 14 taxable at lineal rate x
"
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~
~ 17.Amount of Line 14 taxable at sibling rate x .12 (17)
~
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~ 18. Amount of Line 14 taxable at collateral rate x .15 (18)
~
19. Tax Due (19)
Form REV-1500 EX (Rev. 6-00)
Decedent's Complete Address:
STREET ADDRESS
441 N. River Street
CITY
I STATE PA
I ZIP 17043
W ormleysburg
Tax Payments and Credits:
1. Tax Due (Page Hine 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
Total Credits (A + B + C)
(2)
3. Interest/Penalty jf applicable
D. Interest
E. Penalty
26.49
298.79
0.00
TotallnterestlPenalty (D + 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.
S. Enter the total of line 5 + 5A. This is the BALANCE DUE.
(3) 26.49
(4)
(5) 325.28
(SA)
(5B) 325.28
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes
a. retain the use or income of the property transferred; ........................... ................. 0
b. retain the right to designate who shall use the property transferred or its income; 0
c. retain a reversionary interest; or.... ..................... .............. ........... ..................... 0
d. receive the promise for life of either payments, benefits or care? ................... ............... 0
2. If death occurred after December 12,1982, did decedent transfer property within one year of death without
receiving adequate consideration? ...................... ............... .............................. ................. 0
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?.. 0
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ..................................... .................... ................ C8J
No
~
~
~
~
~
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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 pe~ury. I declare that I have examined this return. including accompanying schedules and statements, and to the best of my knowiedge and belief. it is true, correct
and complete.
~~~~a~!~~~_~!J~reparer oth_er_~h~t~p~~t)al represerl!~!i~~~~_g_n_aH inforrn_~i~n of whlc.l~J?re'parer has~~y'~owledge. _ __ __ _________ __ ___ ____________
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS DATE
Cath~' Green ~ 1 Mountain View Drive
Mechani~l>ul"",PA 17050 <t-J0-o3
SIGN URE OF PERSON R 0 S L FOR FILltiiG f}ETUR -- - --ADDRESS- DATE
~~~~r:~u~:~~:~NTATIVEm
ADDRESS
315 N. Front Street
P. O. Box 741
U"....;"t..n...... DA 1'71/1Q /1'7..11
;3/11/;;3
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the
surviving spouse is 3% [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%
[72 P.S. ~9116 (a) (1.1) (ii)]. The statute does not exemDt 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 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. ~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%. except as noted in 72 P .S. ~9116
1.2) [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% [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.
*'
SCHEDULE A
REAL ESTATE
COMMONWEAlTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
-~-
FILE NUMBER
21 - 01
GREEN, RICHARD F.
All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as lhe
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 which is jointly-owned with right of survivorship must be disclosed on
schedule F.
iTEM
NUMBER
1 NONE
DESCRIPTION
VALUE AT DATE
OF DEATH
TOTAL (Also enter on Line 1, Recapitulation)
'*
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
GREEN, RICHARD F.
I FILE NUMBER
L 21-01
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
NUMBER
1 PNC Account No. 5003244409
DESCRIPTION
VALUE AT DATE
OF DEATH
2,864.36
2
Horace Mann Insurance (refund)
167.60
3
Provident Life Insurance (refund)
20.10
4
Horace Mann Insurance Company (car repair claim check)
703.11
5
1997 Jeep Cherokee
7,625.00
6
PA-40-2001 Income Tax Refund
129.00
7
1040-2001 Income Tax Refund
136.31
8
Blue Cross/Blue Shield refunds
79.50
TOTAL (Also enter on Line 5, Recapitulation)
11,724.98
*'
SCHEDULE F
JOINTLY-OWNED PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
GREEN, RICHARD F.
I FILE NUMBER
I 21 - 01
_ ()117t::-
If an asset was made joint within one year of the decedent's date of death, it must be reported on schedule G.
SURVIVING JOINT TENANT(S) NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A Cathi Jo Green
1 Mountain View Drive
Mechanicsburg, P A 17050
Former Spouse
JOINTLY OWNED PROPERTY:
I LETTER DATE
ITEM
NUMBER FOR JOINT MADE
TENANT JOINT
A
I .--- . . DESCRIPTIoN OF PROPERTY . ----- -------1 % OF -f, D~TE OF DEA~~--
!Include name of financial institution and bank account number DATE OF DEATH; DECO'S VALUE OF
or similar identifying number. Attach deed for jointly-held real VALUE OF ASSET INTEREST. DECEDENT'S INTEREST
~~. ----
Delaware Investments 3,117.93 1,558.97
Growth and Income Fund B
2 A Delaware Investments 317.26 158.63
I Devon Fund B
3 A Delaware Investments 426.03 213.02
! Fund 144
TOTAL (Also enter on line 6, Recapitulation)
1,930.62
'*
J
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
GREEN, RICHARD F.
I FILE NUMBER
21 - 01
I
ITEM
NUMBER
This schedule must be cOl11J'leted and filed if the answer to ""y. of questions 1 through 4 OI1J>age 2 ~es.
,------ --- -- ,--,'----- [-' -_I_ -. _ -- --
, DESCRIPTION OF PROPERTY 'DATE OF DEATH % OF '
IncJudethe name oflhe transferee, their relallonshlpto decedenl and the date of transfer. VALUE OF ASSET DECO'S EXCLUSION TAXABLE VALUE
Attach a copy of the deed for real estate I NTEREST (IF APPLICABLE)
Horace Mann Individual Retirement Annuity
#0570358080
40,000.00 100%
40,000.001
48,057.98'
0.00
2
Horace Mann Retirement Annuity
#0506405200
48,057.98 100%
0.00
TOTAL (Also enter on line 7, Recapitulation)
'*
SCH8JULE H
FUNERAL EXPENSES &
ADMIIIIS1RA1lVE COS1S
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
GREEN, RICHARD F.
FILE NUMBER
21 - 01
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER1, _ _ _
A. FUNERAL EXPENSES:
Cremation SOCIety, Harrisburg, PA
DESCRIPTION
B. ADMINISTRATIVE COSTS:
1.
Personal Representative's Commissions
Cathi J 0 Green
Social Security Number(s) I EIN Number of Personal Representative(s):
2.
Street Address 1 Mountain View Drive
City Mechanicsburg State P A
Year(s) Commission paid 2001
Attorney's Fees Boswell Tintner Piccola Wickersham
Zip 17050
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
4.
City
Relationship of Claimant to Decedent
Probate Fees Cumberland County Register of Wills
State
Zip
5. Accountant's Fees
6.
Tax Return Preparer's Fees Boswell, Tintner, Piccola & Wickersham
7.
1
Other Administrative Costs
Boswell, Tintner, Piccola & Wickersham (disbursements)
2
Cumberland Law Journal (advertising)
Total of Continuation Schedule(s)
TOTAL (Also enter on line 9, Recapitulation)
I__AMOUNT
995.00
WAIVED
2,000.00
106.00
300.00
27.16
75.00
319.03
3,822.19
.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
GREEN, RICHARD F.
3
The Sentinel (advertising)
ScheWIe H
FI.I1l!ICIIExpe\ ses &
Am ir lisbdlive Cosls continued
I FILE NUMBER
21 - 01
110.03
200.00
4
Boswell, Tintner, Piccola & Wickersham (closing costs)
3.00
5
Waypoint Bank (estate checks)
6
Penn DOT (Jeep title transfer)
6.00
Page 2 of Schedule H
*'
SCHEDULE I
DEBTS OF DECEDENT, MORTGAGE
LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
GREEN, RICHARD F.
I FILE NUMBER
21 -01
Include unreimbursed medical expenses.
ITEM
NUMBER
1 Capital One Mastercard (credit card)
DESCRIPTION
2 Citibank (credit card)
3 Sunoco (credit card)
4 AT&T (telephone)
5 D.G.1. (gas bill)
6 PP&L (electric)
7 Macco Auto Repair (accident repair)
8 All Tune & Lube (engine repair)
9 1040-2001 (income tax due)
TOTAL (Also enter on Line 10, Recapitulation)
AMOUNT
505.30
355.48
159.71
141.52
21.21
14.11
998.52
800.68
197.00
3,193.53
REV-151J EX+ (9-00)
'*
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
NUMBER
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
'I FILE NUMBER
21 - 01
RELATIONSHIP TO I
DECEDENT
, OoJlI.olUst Trustaa(s)
1 Daughter
AMOUNT OR SHARE
OF ESTATE
GREEN, RICHARD F,
I.
TAXABLE DISTRIBUTIONS (include outright spousal distributions)
Rebecca A, Green
150% of residuary estate
2 Kati Lynne Green, Minor
Daughter
50% of residuary estate
I .
Enter doliar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover SheJ
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT
BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEE
August 26, 2003
Jeffrey R. Boswell, Esquire
BOSWELL, TINTNER, PICCOLA & WICKERSHAM
3] 5 North Front Street
P. O. Box 74]
Harrisburg, PA ]7108-074]
RE: Richard F. Green Estate
Dear Mr. Boswell:
This is to confirm that I waive any right which I may have, now or at any future time,
to receive compensation for my services as the Executrix of the Estate of Richard F. Green.
I make this waiver unconditionally and irrevocably.
Sincerely yours,
Cathi Jo Green, Executrix
~;~~~, ~~.
iJ '
CJG:clh
WHEREAS, on the 16th
dated July 7th 1997
was admitted to probate as the last will of GREEN RICHARD FRANCIS
(LA~l, t~K~l, M~UUL~)
Register of Wills of CUMBERLAND County, Pennsylvania
Certificate of Grant of Letters
No. 2001-00476 PA No. 21-01-0476
ESTATE OF GREEN RICHARD FRANCIS
(LAbl, tlKbl, M1UUL~j
a/k/a
Late of
GREEN RICHARD F
WORMLEYSBURG BOROUGH
CUM~~KLANU LUUN1Y,
Deceased
Social
day
Security
of May
2001 an instrument
No. 201-40-7517
a/k/a GREEN RICHARD F
late of WORMLEYSBURG BOROUGH CUMBERLAND County, who died on the
24th day of April 2001 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 CATHI JO GREEN
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 16th day of May 2001.
,
**NOTE** ALL NAMES ABOVE APPEAR (LAST, FIRST, MIDDLE)
LAST WILL
OF
RICHARD FRANCIS GREEN
Jeffrey R. Boswell
BOSWELL, SNYDER, TINTNER & PICCOLA
315 North Front Street
Harrisburg, Pennsylvania 17101
T ABLE OF CONTENTS
LAST WILL AND TEST AMENT
OF
RICHARD FRANCIS GREEN
Introductory Clause
........................................... .
1
ITEM I
Direction to Pay Debts with Discretionary Refinancing by Personal
Representative .......................................... 1
ITEM II
Direction to Pay All Taxes from Residuary Estate
1
ITEM III
General Bequest of Personal and Household Effects With a Precatory
Memorandum ........................................... 2
ITEM IV
Residuary Gift to Wife; Contingent Gift to Trustee of The GREEN Family
Trust . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2
ITEM V
The GREEN Family Trust Introductory Provision ..................... 2
(1) Discretionary Payment of All Income to Children ................ 2
(2) Discretionary Payments of Principal for Children .. . . . . . . . . . . . . . .. 3
(3) Division into Shares for Children . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 3
(4) Upon Child's Death to Child's Issue .......................... 3
ITEM VI
Naming the Personal Representative, Personal Representative Succession, ..
Personal Representative's Fees and Other Matters . . . . . . . . . . . . . . .. 3
(1) Naming an Individual Personal Representative. . . . . . . . . . . . . . . . . .. 3
(2) Naming Individual Successor or Substitute Personal Representative ... 3
(3) Final Succession If All Individual Successor Personal
Representatives Cannot Act. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4
ITEM VII
Naming the Trustee, Trustee Succession, Trustee's Fees and Other Matters 4
(1) Naming Individuals as Trustee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4
(2) Individual Trustees Succession . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4
(3) Final Succession If All Individual Trustees Cannot Act. . . . . . . . . . . .. 4
(4) Limitations on Trustees. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4
ITEM VIII
Definition of Personal Representative and Trustee ... . . . . . . . . . . . . . . . . .. 4
ITEM IX
Powers for Personal Representative and Trustee ...................... 5
ITEM X
Marital Deduction Savings Clause for Outright Bequest ................. 5
ITEM XI
Provision for Trustee to Act as Trustee for Beneficiary Under Age Twenty-
One .................................................. 5
ITEM XII
Trustee's Discretion in Making Payments to a Person Under Age Twenty-
One, Incompetent, or Incapacitated Person ..................... 6
ITEM XIII
Discretion Granted to Personal Representative in Reference to Tax
Matters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 6
ITEM XIV
Appointment of Ancillary Representative . . . . . . . . . . . . . . . . . . . . . . . . . . .. 7
ITEM XV
Definition of Children .......................................... 7
ITEM XVI
ii
DefInition of Words Relating to the Internal Revenue Code. . . . . . . . . . . . .. 7
ITEM XVII
Provision for Appointment by a Married Person of a Testamentary
Guardian. Appointment of a Successor or Substitute Testamentary
Guardian. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8
ITEM XVIII
Statement by Testator of Intent Not to Exercise Power of Appointment 8
ITEM XIX
Simultaneous Death Provision Presuming BenefIciary Predeceases Testator 8
ITEM XX
Payment of Funeral Expenses and Expenses of Last Illness of Income
BenefIciary ............................................. 9
ITEM XXI
Perpetuities Savings Clause ...................................... 9
Testimonium Clause ........................................... 9
Attestation Clause ............................................. 9
ill
LAST WILL AND TEST AMENT
OF
RICHARD FRANCIS GREEN
Introductorv Clause. I, RICHARD FRANCIS GREEN, a resident of and
domiciled in the Township of Silver Spring, County of Cumberland and Commonwealth
of Pennsylvania, do hereby make, publish and declare this to be my Last Will and
Testament, hereby revoking all Wills and Codicils at any time heretofore made by me.
I am married to CATHI JO GREEN.
I have two living children: REBECCA ANNE GREEN, born December 2, 1981
and KAT! LYNNE GREEN, born April 8, 1984.
ITEM I
Direction to Pav Debts with Discretionarv Refinancing bv Personal
Reoresentative. I direct that all my legally enforceable debts, secured and unsecured, be
paid as soon as practicable after my death. I direct that my Personal Representative
may cause any debt to be carried, renewed and refinanced from time to time upon such
terms and with such securities for its repayment as my Personal Representative may
deem advisable taking into consideration the best interest of the beneficiaries hereunder.
ITEM II
Direction to Pav All Taxes from Residuarv Estate. I direct that all estate,
inheritance, succession, death or similar taxes (except generation-skipping transfer taxes)
assessed with respect to my estate herein disposed of, or any part thereof, or on any
bequest or devise contained in this my Last Will (which term wherever used herein shall
include any Codicil hereto), or on any insurance upon my life or on any property held
jointly by me with another or on any transfer made by me during my lifetime or on any
other property or interests in property included in my estate for such tax purposes be
paid out of my residuary estate and shall not be charged to or against any recipient,
beneficiary, transferee or owner of any such property or interests in property included in
my estate for such tax purposes.
Page 1
ITEM III
General Bequest of Personal and Household Effects With a Precatory
Memorandum. I give and bequeath all my personal and household effects of every kind
including but not limited to furniture, appliances, furnishings, pictures, silverware, china,
glass, books, jewelry, wearing apparel, boats, automobiles, and other vehicles, and all
policies of fire, burglary, property damage, and other insurance on or in connection with
the use of this property, to my wife, CATHI JO GREEN, if she shall survive me. If my
wife shall not survive me, I give and bequeath all this property to my children surviving
me, in approximately equal shares; provided, however, the issue of a deceased child
surviving me shall take per stirpes the share their parent would have taken had he or she
survived me. If my issue do not agree to the division of the property among themselves,
my Personal Representative shall make such division among them, the decision of my
Personal Representative to be in all respects binding upon my issue. I request that my
wife, my Personal Representative and my issue abide by any memorandum by me
directing the disposition of this property or any part thereof. This request is precatory
and not mandatory. If any beneficiary hereunder is a minor, my Personal Representative
may distribute such minor's share to such minor or for such minor's use to any person
with whom such minor is residing or who has the care or control of such minor without
further responsibility and the receipt of the person to whom it is distributed shall be a
complete discharge of my Personal Representative. The cost of packing and shipping
such property shall be charged against my estate as an expense of administration.
ITEM IV
Residuarv Gift to Wife: Contingent Gift to Trustee of The GREEN Familv Trust.
I give, devise and bequeath all the rest, residue and remainder of my property of every
kind and description (including lapsed legacies and devises) wherever situate and
whether acquired before or after the execution of this Will, to my wife, CATHI JO
GREEN, if she shall survive me. If she shall not survive me, then I give, devise and
bequeath all of the property to the Trustee of the GREEN Family Trust. The GREEN
Family Trust shall be administered as hereinafter set forth.
ITEM V
The GREEN Familv Trust Introductorv Provision. The GREEN Family Trust
shall be held, administered and distributed as follows:
(1) Discretionarv Payment of All Income to Children. Commencing with the
date of my death, my Trustee shall pay to or apply for the benefit of anyone or more of
my children, until division into shares for children as hereafter provided all of the net
income from the GREEN Family Trust in convenient installments in such shares and
proportions as my Trustee in its sole discretion shall determine primarily for the medical
care, education, support and maintenance in reasonable comfort of my children, taking
Page 2
into consideration to the extent my Trustee deems advisable, any other income or
resources of my children known to my Trustee.
(2) Discretionarv Payments of Principal for Children. Prior to division into
shares for children as hereafter provided, my Trustee may pay to or apply for the benefit
of anyone or more of my children such sums from the principal of the GREEN Family
Trust in such shares and proportions as in its sole discretion shall be necessary or
advisable from time to time for the medical care, education, support and maintenance in
reasonable comfort of my children, taking into consideration to the extent the Trustee
deems advisable, any other income or resources of my children known to my Trustee.
Any payment or application of benefits for a child of mine pursuant to this Paragraph
shall be charged against this Trust as a whole rather than against the ultimate
distributive share of the beneficiary to whom or for whose benefit the payment is made.
(3) Division into Shares for Children. Upon or after the death of my wife and
me, when no child of mine is living who is under the age of Twenty-five (25) years, my
Trustee shall divide this Trust as then constituted into equal separate shares so as to
provide One (I) share for each then living child of mine and One (1) share for each
deceased child of mine who shall leave issue then living. Each share shall be distributed
or retained in Trust as hereinafter provided.
(4) Upon Child's Death to Child's Issue. After division into shares for
children, upon the death of a child of mine prior to complete distribution of his or her
share, the undistributed balance of the child's share shall be distributed per stirpes to his
or her then living issue, or in default of such issue, per stirpes to my then living issue.
Provided, however, that if any portion of the share would otherwise be distributed to a
person for whose benefit a trust is then being administered under this the GREEN
Family Trust, that part shall instead be added to that trust and shall thereafter be
administered and distributed according to its terms.
ITEM VI
Naminl! the Personal Reoresentative. Personal Representative Succession.
Personal Representative's Fees and Other Matters. The provisions for naming the
Personal Representative, Personal Representative succession, Personal Representative's
fees and other matters are set forth below:
(I) Naminl! an Individual Personal Representative. I hereby nominate,
constitute, and appoint as Personal Representative of this my Last Will and Testament
CATHI JO GREEN and direct that she shall serve without bond.
(2) Naminl! Individual Successor or Substitute Personal Representative. If my
individual Personal Representative should fail to qualify as Personal Representative
hereunder, or for any reason should cease to act in such capacity, the successor or
Page 3
substitute Personal Representatives who shall also serve without bond shall be ROBERT
M. GILBERT and JOAN GILBERT, of 24 Goldenrod Drive, Carlisle, PA 17013. If
any individual Personal Representative named herein should fail to qualify as Personal
Representative hereunder, or for any reason should cease to act in such capacity, the
remaining individual Personal Representatives named herein shall continue to serve
without a successor or substitute.
(3) Final Succession If All Individual Successor Personal Reoresentatives
Cannot Act. If all my individual successor Personal Representatives should fail to
qualify as Personal Representative hereunder, or for any reason should cease to act in
such capacity, then the successor or substitute Personal Representatives who shall also
serve without bond shall be ALBERT SNYDER and ANNELLE SNYDER, of Star
Route, H. C. Box 68, Pleasant Mount, PA 18453. If any of them should fail to qualify
or for any reason should cease to act in such capacity the remaining individual Personal
Representatives shall serve without a successor.
ITEM VII
Naming the Trustee. Trustee Succession. Trustee's Fees and Other Matters. The
provisions for naming the Trustee, Trustee succession, Trustee's fees and other matters
are set forth below:
(1) Naming Individuals as Trustee. I hereby nominate, constitute, and appoint
as Trustees of this my Last Will and Testament ROBERT M. GILBERT and JOAN
GILBERT and direct that they shall serve without bond.
(2) Individual Trustees Succession. If any individual Trustee should fail to
qualify as Trustee hereunder, or for any reason should cease to act in such capacity, the
remaining individual Trustees shall continue to serve without a successor or substitute.
(3) Final Succession If All Individual Trustees Cannot Act. If all my individual
Trustees should fail to qualify as Trustee hereunder, or for any reason should cease to
act in such capacity, then the successor or substitute Trustees who shall also serve
without bond shall be ALBERT SNYDER and ANNELLE SNYDER. If any of them
should fail to qualify or for any reason should cease to act in such capacity the remaining
individual Trustees shall serve without a successor.
(4) Limitations on Trustees. No person who at any time is acting as Trustee
hereunder shall have any power or obligation to participate in any discretionary authority
which I have given to the Trustee to pay principal or income to such person, or for his or
her benefit or in relief of his or her legal obligations.
Page 4
ITEM VIII
Definition of Personal Reoresentative and Trustee. Whenever the word "Personal
Representative" and/ or the word "Trustee", or any modifying or substituted pronoun
therefor are used in this my Will, such words and respective pronouns shall include both
the singular and the plural, the masculine, feminine and neuter gender thereof, and shall
apply equally to the Personal Representative and/ or Trustee named herein and to any
successor or substitute Personal Representative and/ or Trustee acting hereunder, and
such successor or substitute Personal Representative and/ or Trustee shall possess all the
rights, powers and duties, authority and responsibility conferred upon my Personal
Representative and/ or Trustee originally named herein.
ITEM IX
Powers for Personal Reoresentative and Trustee. By way of illustration and not
of limitation and in addition to any inherent, implied or statutory powers granted to
Personal Representatives and Trustees generally, my Personal Representative and
Trustee is specifically authorized and empowered with respect to any property, real or
personal, at any time held under any provision of this my Will: to allot, allocate between
principal and income, assign, borrow, buy, care for, collect, compromise claims, contract
with respect to, continue any business of mine, convey, convert, deal with, dispose of,
enter into, exchange, hold, improve, incorporate any business of mine, invest, lease,
manage, mortgage, grant and exercise options with respect to, take possession of, pledge,
receive, release, repair, sell, sue for, to make distributions or divisions in cash or in kind
or partly in each without regard to the income tax basis of such asset, and in general, to
exercise all the powers in the management of my Estate which any individual could
exercise in the management of similar property owned in his or her own right, upon such
terms and conditions as to my Personal Representative and Trustee may seem best, and
to execute and deliver any and all instruments and to do all acts which my Personal
Representative and Trustee may deem proper or necessary to carry out the purposes of
this my Will, without being limited in any way by the specific grants of power made, and
without the necessity of a court order.
ITEM X
Marital Deduction Savings Clause for Outright Beauest. It is expressly provided
that the grant of rights, powers, privileges and authority to my Personal Representative
in connection with the imposition of duties upon my Personal Representative by any
provision of this my Will or by any statute relating thereto shall not be effective if and to
the extent that the same, if effective, would disqualify the marital deduction as provided
for herein. It is expressly provided that my Personal Representative shall not in the
exercise of its discretion make any determination inconsistent with the foregoing
intention.
Page 5
ITEM XI
Provision for Trustee to Act as Trustee for Beneficiary Under Age Twentv-one.
If any share hereunder becomes distributable to a beneficiary who has not attained the
age of Twenty-one (21), such share shall immediately vest in the beneficiary, but
notwithstanding the provisions herein, my Trustee shall retain possession of the share in
trust for the beneficiary until the beneficiary attains the age of Twenty-one (21), using so
much of the net income and principal of the share as my Trustee deems necessary to
provide for the medicai care, education, support and maintenance in reasonable comfort
of the beneficiary, taking into consideration to the extent my Trustee deems advisable
any other income or resources of the beneficiary or his or her parents known to my
Trustee. Any income not so paid or applied shall be accumulated and added to principal.
The beneficiary's share shall be paid over and distributed to the beneficiary upon
attaining age Twenty-one (21), or if he or she shall sooner die, to his or her personal
representatives. My Trustee shall have with respect to each share so retained all the
powers and discretions it had with respect to the trusts created herein generally.
ITEM XII
Trustee's Discretion in Making Pavments to a Person Under A~e Twentv-one.
Incomoetent. or Incapacitated Person. In case the income or principal payment under
any trust created hereunder or any share thereof shall become payable to a person under
the age of Twenty-one (21), or to a person under legal disability, or to a person not
adjudicated incompetent, but who, by reason of illness or mental or physical disability, is,
in the opinion of my Trustee unable properly to administer such amounts, then such
amounts shall be paid out by my Trustee in such of the following ways as my Trustee
deems best: (1) directly to the beneficiary; (2) to the legally appointed guardian of the
beneficiary; (3) to some relative or friend for the medical care, education, support and
maintenance in reasonable comfort of the beneficiary; (4) by my Trustee using such
amounts directly for the beneficiary's care, support and education; (5) to a custodian for
the beneficiary under the Uniform Gifts or Transfers to Minors Act.
ITEM XIII
Discretion Granted to Personal Reoresentative in Reference to Tax Matters. My
Personal Representative as the fiduciary of my estate shall have the discretion, but shall
not be required when allocating receipts of my estate between income and principal, to
make adjustments in the rights of any beneficiaries, or among the principal and income
accounts to compensate for the consequences of any tax decision or election, or of any
investment or administrative decision, that my Personal Representative believes has had
the effect, directly or indirectly, of preferring one beneficiary or group of beneficianes
over others; provided, however, my Personal Representative shall not exercise its
discretion in a manner which would cause the loss or reduction of the marital deduction
as may be herein provided. In determining the state or federal estate and income tax
Page 6
liabilities of my estate, my Personal Representative shall have discretion to select the
valuation date and to determine whether any or all of the allowable administration
expenses in my estate shall be used as state or federal estate tax deductions or as state
or federal income tax deductions and shall have the discretion to me a joint income tax
return with my wife.
ITEM XIV
Aooointment of Ancillarv Reoresentative. If it becomes necessary for a
representative of my estate to quallfy in any jurisdiction other than the State of my
domicile at the time of my death, then to the extent that I may legally do so, I hereby
nominate, constitute, and appoint my Personal Representative named in this Will as my
representative in such jurisdiction and direct that such Personal Representative shall
serve without bond. If for any reason my Personal Representative is unable or unwilling
to serve as such representative or cannot qualify as such representative, then I hereby
appoint my Personal Representative named herein to designate (to the extent that it may
legally do so) a person or a corporation to serve as my representative and request that
such person or corporation shall serve without bond. Any representative named as
provided herein (to the extent that it may legally do so) shall have in such jurisdiction all
the powers and duties conferred or imposed on my Personal Representative by the
provisions of this Will.
ITEM XV
Definition of Children. For purposes of this Will, "children" means the lawful
blood descendants in the first degree of the parent designated; and "issue" and
"descendants" mean the lawful blood descendants in any degree of the ancestor
designated; provided, however, that if a person has been adopted, that person shall be
considered a child of such adopting parent and such adopted child and his or her issue
shall be considered as issue of the adopting parent or parents and of anyone who is by
blood or adoption an ancestor of the adopting parent or either of the adopting parents.
The terms "child," "children," "issue," "descendant" and "descendants" or those terms
preceded by the terms "living" or "then living" shall include the lawful blood descendant
in the first degree of the parent designated even though such descendant is born after
the death of such parent.
The term "per stirpes" as used herein has the identical meaning as the term
"taking by representation" as defined in the Pennsylvania Probate Code.
ITEM XVI
Definition of Words Relating to the Internal Revenue Code. As used herein, the
words "gross estate," "adjusted gross estate," "taxable estate," "unified credit," "state death
tax credit," "maximum marital deduction," "marital deduction," "pass," and any other
Page 7
word or words which from the context in which it or they are used refer to the Internal
Revenue Code shall have the same meaning as such words have for the purposes of
applying the Internal Revenue Code to my estate. For purposes of this Will, my
"available generation-skipping transfer exemption" means the generation-skipping transfer
tax exemption provided in section 2631 of the Internal Revenue Code of 1986, as
amended, in effect at the time of my death reduced by the aggregate of (1) the amount,
if any, of my exemption allocated to lifetime transfers of mine by me or by operation of
law, and (2) the amount, if any, I have specifically allocated to other property of my
gross estate for federal estate tax purposes. For purposes of this Will if at the time of
my death I have made gifts with an inclusion ratio of greater than zero for which the gift
tax return due date has not expired (including extensions) and I have not yet flIed a
return, it shall be deemed that my generation-skipping transfer exemption has been
allocated to these transfers to the extent necessary (and possible) to exempt the
transfer(s) from generation-skipping transfer tax. Reference to sections of the Internal
Revenue Code and to the Internal Revenue Code shall refer to the Internal Revenue
Code amended to the date of my death.
ITEM XVII
Provision for Aooointment bv a Married Person of a Testamentarv Guardian.
Aooointment of a Successor or Substitute Testamentarv Guardian. If my wife shall
predecease me, or if my wife dies after my death without having appointed a
testamentary guardian for any minor child or children of ours, then I hereby nominate,
constitute, and appoint THOMAS GREEN and CINDY GREEN as testamentary
guardian of the person and the property of such minor child or children and to the
extent allowed by law direct that such guardian shall serve without bond. If THOMAS
GREEN and CINDY GREEN dies, resigns, or refuses or is otherwise unable to act,
then I appoint ROBERT M. GILBERT and JOAN E. GILBERT as testamentary
guardian of the person and property of such minor child or children and direct that such
guardian shall also serve without bond.
ITEM XVIII
Statement bv Testator of Intent Not to Exercise Power of Aooointment. I hereby
refrain from exercising any power of appointment that I may have at the time of my
death.
ITEM XIX
Simultaneous Death Provision Presuming Beneficiarv Predeceases Testator. If
any beneficiary and I should die under such circumstances as would make it doubtful
whether the beneficiary or I died first, then it shall be conclusively presumed for the
purposes of this Will that the beneficiary predeceased me.
Page 8
ITEM XX
Pavment of Funeral Exoenses and Exoenses of Last Illness of Income Beneficiarv.
On the death of any person entitled to income or support from any Trust hereunder, my
Trustee is authorized to pay the funeral expenses and the expenses of the last illness of
such person from the principal of the Trust from which such person was entitled to
income or support.
ITEM XXI
Peroetuities Savings Clause. Notwithstanding anything herein to the contrary, the
trusts created hereunder shall terminate not later than Twenty""ne (21) years after the
death of the last survivor of my wife and issue living on the date of my death, when my
Trustee shall distribute each remaining trust hereunder to the beneficiary or beneficiaries
of the current income thereof, and if there is more than one beneficiary, in the
proportion in which they are beneficiaries or if no proportion is designated in equal
shares to such beneficiaries.
Testimonium ClarIN WITNESS WHEREOF, I have hereunto set my hand
and affixed my seal this day of July, 1997.
'~f~ ~(SEAL)
ICHARD FRANCIS GREEN
Attestation Clause. The foregoing Will was this 7ft.. day of July, 1997, signed, sealed,
published and declared by the Testator as and for his Last Will and Testament in our
presence, and we, at his request and in his presence, have hereunto subscribed our names as
witnesses on the above date.
~M. /?
, ,
,
of ~~A~ --A
/
of
Page 9
PROOF OF WILL
Commonwealth of Pennsylvania
Self-Proving Affidavit
County of Dauphin
We, RICHARD FRANCIS GREEN, and Jeffrey R. Boswell and
Connie L. Hardv ,the Testator 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 Testator signed and executed the instrument as his
Last Will and that he had signed willingly (or willingly directed another to sign for him),
and that he executed it as his free and voluntary act for the purposes therein expressed,
and that each of the witnesses, in the presence and hearing of the Testator, signed the
Will as witness and to the best of our knowledge the Testator was at that time eighteen
years of age or older, of sound mind, and under no constraint or undue influence.
/J, ~ /-/
K<-c.LI /J~ / fv-<---/
RICHARD FRANCIS GREEN
~~
Wu L
( z-...~ Al~
Wane
Subscribed, sworn to, and acknowledged before me by RICHARD FRANCIS
GREEN, the Testator and subscribed and sworn to before me by
Jeffrev R. Boswell and Connie L. Hardv ,witnesses, this .2t.h. day
of July, 1997.
~A--<t-A f-./)"- Id. (Seal)
Notary Public f~~
My Commission Expires: /~I/-3/"1;r
NOTe-RIAL SEAL
5 'R"H C ; PPLEW, Notar'f Public
1"'.1 r-. .... ;-\, n 1.... 1"98
\,'1\" C0!111Tlissicn Ex~~res ~~c....;j, 17
Page 10 'Harrisburg, Pt, OtJupnm '_ounly
.
PROOF OF PUBLICATION
Gllllor
"1t0,03
;C7~
. "liB/of
State of Pennsylvania,
County of Cumberland.
Sherry Clifford, Classified Ad Manager of THE SENTINEL
,
of the County and State aforesaid, being duly sworn, deposes and says that THE SENTINEL, a newspaper of
general circulation in the Borough of Carlisle, County and State aforesaid, was established December 13th,
1881, since which date THE SENTINEL has been regularly issued in said County, and that the printed notice
or publication attached hereto is exactly the same as was printed and published in the regular editions and
issues of THE SENTINEL on the following dates, viz
Copy of Notice of Publication
ESTATE NOTICE
NOTICE IS HEREBY GIV-
EN that the Register of
Wills has granted Letters
Testamentary to the per-
son named. All persons
having claims or
demands against the
estate are requested to
make known the claim
or demand, and all
persons indebted to the
estate are requested to
make payment, without
delay, to the Executrix
or to her attorneys
named below:
The Estate of RICHARD
FRANCIS GREEN, late
of the Borough of Worm.
leysburg, County of
Cumberland and State
of Pennsylvania.
Executrix: Cathi Jo Green
Attorney: Jeffrey A.
Boswell, Esquire
Boswell, Tlntner, Piccola &
Wickersham
315 N. Front Street, P.O.
Box 741
Harrisburg, PA 17108-0741
May 23, 30 & June 6, 2001
Affiant further deposes that he is not interested in
the subject matter of the aforesaid notice or
advertisement, and that all allegations in the
foregoing statement as to time, place and character
of publication are true.
Sworn to and subscribed before me this
day of June , 2001.
&~u&= Q'~
Notary Public
6th
My commission expires:
NOTARIAL SEAL
SHIRLEY O. DURNIN, I-Jotary Public
Carlisle Bora., Cumberland COUiliV
M Commission Expires Au . 9, 2003
PROOF OF PUBLICATION OF NOTICE
IN CUMBERLAND LAW JOURNAL
(Under Act No. 587, approved May 16, 1929), P. L.1784
STATE OF PENNSYLVANIA:
ss.
COUNTY OF CUMBERLAND :
Roger M. Morgenthal, Esquire, Editor ofthe Cumberland Law Journal, of the County
and State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland
Law Journal, a legal periodical published in the Borough of Carlisle in the County and State
aforesaid, was established January 2, 1952, and designated by the iocal courts as the official legal
periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly
issued weekly in the said County, and that the printed notice or publication attached hereto is
exactly the same as was printed in the regular editions and issues of the said Cumberland Law
Journal on the following dates,
Viz
JUNE 1,2001
Affiant further deposes that he is authorized to verify this statement by the Cumberland
Law Journal, a legal periodical of general circulation, and that he is not interested in the subject
matter of the aforesaid notice or advertisement, and that all allegations in the foregoing
statements as to time, place and character of publication are
I
Roger M. Morgenthal, Editor
.
GreeD. Richard F.. dec'd.
Late of the Borough ofWormleys.
burg.
ExecutriX: Cathi Jo Green.
Attorneys: Jeffrey R. Boswell,
Esquire. Boswell. TIntner. Piccola
& Wickersham, 315 N. Front
Street. P.O. Box 741. Harrisburg.
PA 17108-0741.
SWORN TO AND SUBSCRIBED before me this
1 day of JUNE. 2001
NOTARlALSEAL
LOIS E. SNYDER, __ "'......
CaI1iaIeBoro ~ r.......
My CommissIoO Exp/l8S March ~
Express Checking Account Statement
. I'NC Bank
For the period 06/20/2001 to 07/19/2001
RICHARD ~GREEN
441 N RIVER ST 2
lEMDYNE PA 17043-1123
0. PNCBAN<
Primary account number: 50.0324-4409
Page 1 of 1
NU!TIber of enclosures: 0
...
'It For 24-hour customer service or
current rates: Call '~8a8-PNC-BANK
t1!SJ Write to: Customer Service
PO Box 609
Pittsburgh PA 15230.9738
S Visit us at www.pncbank.com
iii TDO terminal: 1-800.531-1648
For heC\ring itnp~u:ed dients only
- -~
y on l~arned yonr own. money and YOll try In keep lip on the latest [mandaI nel,,"S. So why do YOll need a financial advisor?
Fil1anciallllarkets h,-L\'c hecome incredibly complex and your investment choices are endless. PNC Brokerage Corp Investment
Consullants can help you in lUall)' ways. They have the time and expenise to investigate and understand to day's changing
fillandall'narketplace. An Invesrment Consulwnt call help you develop an investrnent strategy tailored to nwet your financial
Iweds. CorHarl a PNC Brokerage Corp Investment Consultant to set up a free no obligation consultation. PNC Brokerage
Investment Consultants can be re~:rhed through our Custorner Senrlce Center at 1-800-7\l2-6111, its web-she at
W'\"\-'.pncbr()k(~Tage.com or an)' Pt)iC Bank branch nnke.
Express Checking Account Summary
Account number: 50-0324-4409 Account Link $ number: 0201407517
Richard F Green
Balance Summary
Please see the Activity Detail section for
additional information.
Deposits and
other additions
.00
Checks and ottler
deductions
2,81':'4.30
Ending
balance
.00
Average monthly
balance
1,2,'11.22
Charges
and fees
.00
Activity Detail
Other Deductions
Date
07;'O:!
07,/03
Amount
00
DescriPtion
Ol1lsUlIlding Item Close
Debil Memo Rdercw::e No. 02743.17.15
'.J:i,
2,1;C..1.3(;
There were 2 Other Deductions totaling
$2.864.36.
'"
Daily Balance Detail
Date
Of)./20
Balance
2,,~Cd.3i:J
Date
07/02
Balance
2,8().t.36
Date
07/03
Balance
.00
.....-........
r _~ _ .............._
"
COMMONWEALTH OF PENNSYLVANIA
PUBLIC SCHOOL EMPLOYEES' RETIREMENT SYSTEM Dr Ii \Je-
Mailing Address
PO Box 125
Harrisburg PA 17108-0125
Toll-Free -1-888-773-7748
(l-888-PSERS4U)
Local- 717-787-8540
Building Location
5 North 5th Street
Harrisburg P A
Web AddreJ"s: www.psers.slale.pa.us
AUGUST 14, 2000
-,
"
")
RICHARD F GREEN
1 MOu~TAIN VIEW DR
MECHANICSBu~G PA 17050
5,5, # 201-40-7517
RET TYPE - EARLY
Termination Date - June 6, 2000
Retirement Date. June 7, 2000
INITIAL RETIREMENT BENEFIT (ESTIMATED)
Your retirement has been calculated based on your option selection and the latest salaries
and service on file in the Public School Employees' Retirement System (PSERS), The terms
of your retirement plan will be binding unless you file the enclosed "Intent to Change the
Terms of the Retirement Plan (PSRS-1242),"
You selected the Maximum Single Life Annuity and decided to withdraw your total
contributions and interest,
Beginning September 2:, 2000, your estimated monthly benefit w~ ~2~ .
In 7 to 10 business days two payments will be issued on your ~f. The payment for
$40,000,00 (outlined below) will be directly rolled over to HORACE MANN LIFE INS CO,
$ 40,000,00
+ .00
$ 40,000,00
Partial Lump Sum
Installment Interest
Total Benefit to be Directly Rolled Over
In addition a payment for $ 11,600.80 (outlined below) will be sent to you.
...
...
...
$ 1,966,32
10,650,19
332,24
,00
1,347,95
$11,600,80
Initial Monthly Payment (06/07/2000 to 08131/::000)
Partial Lump-Sum Payment
Installment Interest
Tax Deducted from Initial Monthly Payment
Tax Deducted from Partial Lump-SumlInterest
Net Check
A 20 percent federal withholding tax has been deducted from the taxable portion of your
payment, You may still elect to roll over to an IRA or another employer plan that accepts
your rollover, any or all of the $ 6,739,76 taxable portion, within 60 days of the receipt of
Please read reverse side for more information
Dated Material Enclosed
I /III~ IIIII~ III II~ 11111 IIIIII11~ IIIIIIII~ 11111 III~ IIIIII~IIIIIIIIIIIIIIIII 111111111111'
.OL000201407S17t27*
111111111111111111111111111111111111111111111
81114.PPR.l.l27 -813401-
.ANNUITY APPLICATlQN (':\ l;f L'''' .
-1; ,i [)~) IJ ') ;/Lt~;YOD
--
Horace mann life Insurance (ompam.(
HOME OFFICE - .1 HORACE MANN PLAZA
SPRINGFIElD ILLINOIS 627150001
ANNUITANT INFORMATION
Initial Em?!qv:r or ')avor Nlme \
t v M~H~. C\"'^
T7 ~(C' C C, ~ I 'fit
Se'
OF
Social Security ,
1.'0 : Yo :7517
rl~ [~~N Ie ~ bL\~ a
Telephone
0.5 I Ii. -.57~
Is the annuity now applied for to replace any life insur-
ance or annujJ:ies in force in this or any other company?
DYES I.8' NO (If yes, give Name of Company or Companies)
PLAN INFORMATION
TAX STATUS; ~.~_
~Tax Deferred II.P( 4031l>.U/
o IRA <; '.. ,,~
-l! L/'D1.:J /
o Spousal IRA " \..,
o Master Pension Plan II.R.C. 401 lall
o SEP-IRA
o HR-l 0 IKeoghl
o Non-Qualified
oOthe,
'=.J FIXED ACCOUNT
o Group
o Flexible Premium. . . . . . .
o Single Premium. . . .
FIXED AND VARIABLE ACCOUNT
o Individual
Initial Renewal Period_Years
Initial Renewal Period_Years
HOME OFFICE USE ONLY: INot APpNcable in PA & W VA)
State
Year
( 1
~/ ( \.1
-J...
1) 1.5 I
l"Y \ 1
l-I~c 1c...v Ie> ul
Birthdate
Mo. Day
Owner (If other rh,Jn Annuitant)
St reet Address
City
State
Zip
Social Security
,
BirthclClte
Mo. uay I Year
Relationship 10 Annuitant
BILLING INFORMATION
Effective Date
Mo. ~ Day
,
~-
l No. Pays
Maturitv Date
Mo. ~ Day
,
, Year
,
Year
Level Mode Premo
$
Month of First Reduction
9...-9;;
Total First Year Prem List Bd1 NUlT'ber
1 QO.Oo 37- 1~1.
BUST BILL DC.a.M. DDIRECT
0,/,2 0,/,2
0',110 01110
o 119L 01/9
.fiir I _1.1"
DSINGLE PREM.
o Annuallv
o Semiannually
o Quarterly
o Monthly
BENEFICIARY INFORMATION
Primary Beneficiary":
Relationship
-S~. vv.JP
-- -------
elations hip
r, h ' G
.l E\~C ;__,J~___A~~'Y__ __ __
Successor Beneficiary:
COMMENTS AND SPECIAL REQUESTS:
THE AMOUNT OF ANNUITY PAYMENTS AND CASH VALUE PAYABLE FROM THE VARIABLE ANNUITY SEPARATE
ACCOUNT UNDER THE CONTRACT ISSUED PURSUANT TO THIS APPLICATION ARE VARIABLE AND ARE NOT
GUARANTEED BUT WILL INCREASE OR DECREASE BASED UPON THE INVESTMENT EXPERIENCE OF THE SEPARATE
ACCOUNT.
It is hereby stated that each of the statements and answers given above are full, comple~nd true to the best of
my knowled9fi- ^ ~ I, () ,if.'-/} \J
Dated at ,}IV LiL-c.;,\,.c.'-"'-M".flJ I r Ii thiS ./ ( -," day of ",fr...RAr-'l'-<-O-u.! ,19 93
X t~jJ r )~/ t1
Owner's Signature (If other than Annuitant) Annuitant's Signature
S~9nature of parent if AA'n.uitar\ti is under age 15
\ : \ . '\ t ,r. ' . . . ~.
". 'i. ...." I . \ . ." '-1 ~I. (:' "-
\ .J vY1../.;,J~.j' j .(( .A"~1/ti_.'> I' ..J t '{ I
Witness or Licensed Agent's Signature. State and Agent Code
IL-A109Al
Employer Representative (ff requiredbv Employer)
Title
PART 1
SUITABiliTY QUESTIONNAIRE
(ReQuired 'In All Combination Contracts)
Horace mann life Insurance Companll
HOME OFFICE ~-l.HORAC:::MANN PLAlA:
SPRINGFIELD. ILLINOIS 62715-0001
TAX DEFERRED ANNUITY [I.R.C. 403(b)] INFORMATION
(Required on all Tax Deferred Annuity Applications)
SOURCE OF PURCHASE PA YMENTS,
Di( Employee - Contributions through salary reduction agreement:
Has salary reduction agreement been completed?
If no, why not7
t&1. Yes
o No
o Employer - Contributions as employee benefit:
$
$
._-----------~---------------------------------_.__._---------.------.--------.-------.-------------------.-------
EXCLUSION ALLOWANCE INFORMATION
1. State (or citY, district, etc.) retirement system.
2. Contract salary for tax year.
3. Years of service completed with current employer through prior calendar year.
4. Years of past service (all districts) worked while covered by current retirement system
in which the annuitant participates.
5. Total TDA contributions to date by current employer to all companies.
6. Current annual TDA contributions to all companies.
7. Annuitant's contribution to retirement benefit of state retirement system for public
school employees from taxable income as a percent of contract salary.
Annuitant's Signature: X
~
AGENT'S REPORT
1. PA
2. $- YO
3. '11
4. J~
5. $ 3000
6. $ <Zi,oo
\ i"
5-
7. $ Y
Based on the information available to you, do you believe the annuity as applied for to be a suitable investment for
the proposed Annuitant? t& Yes 0 No .
To the best of your knowledge will this annuity now applied for change or replace any life insurance or annuities
now in forcr-with this or any other compa')-y? 0 Yes ~ No
f" /'.
\ \ \. \ 12 rl \ "7
:- J .yrv,;U u if Am-hl ->
Agent's Signature State Code
Signed
Dated:
d - JD - g.3
IL-Al09A2
3G99
Agent Code
I
PART 2
(j)
"Grate mann.
In8Ul1ng AIMf'lCII" Eclucallonll ComrTllJr'Ilty
;r'A,"
- vJ
J
. i
Retlremel'1t Annuities and
Life, Auto, Homeowners and
Grouplnlurance ___ _u
The Horace Mann Companies
1 Horace Mann Plaza
Springfield. Illinois 62715-0001
(217) 789.2500
October 4,2001
Cathi Jo Green
I MOlUltain View Dr.
Mechanicsburg, P A 17050
Subject: Annuity contracts #0570358080 and 0506405200
Claim #0104040
New Supplemental Contract S20279
Dear Ms. Green:
Thank you for choosing a Horace Mann settlement option for the proceeds of your husband's
annuity contracts.
So you can begin receiving payments according tu the retirement income option you selected,
your husband's annuity contracts #0570358080 and #0506405200 have been terminated and
replaced with the Annuity Income Statement of Benefits enclosed.
Annuity contract #0570358080 had a total cash value of $40,000.00 to which we added interest
of$II1.91. Annuity contract #0506405200 had a total cash value of $48,057.98 to which we
added interest of $134.45.
Currently this contract is earning 5 percent interest annually.
We will electronically deposit your first installment into your checking accolUlt at PNC Bank in
approximately three days. Subsequent payments. will be deposited in your bank account by
electronic fund transfer on the first working day of the month your payment is due. Assuming
that the current interest rate remains the same and no withdrawals are made, your final payment
of $928 .03 will be issued September I, 20 I!.
In addition, as we IUlderstand tax regulations, you must report these payments to the Internal
Revenue Service as taxable income for the year you receive them.
To be sure your payments reach you without delay, notify us immediately of any address or bank
changes.
www.horacemann.com
Page 2
If you have any questions or need assistance, please let us know by calling our toll-free number.
1-800-999-1030. Refer to your new supplemental contract #520279. We will be glad to help
you.
Sincerely,
Samantha Utterback
Annuity Benefits Specialist I
Annuity Benefits and Claims
cc: Donald Fronk #3689
717-697-5976
Horate mann.
@,
Retirement Annuities and
Ule, Auto, HOmeOWMrs. and
Group Insurance
The Horace Mann Companies
1 Horace Mann Plaza
Springfield, Illinois 62715-0001
(217) 769-2500
Insurln<" ~'"Ierica's Educational Community
Annuity Income Statement of Benefits
Annuitant: Cathi Jo Green
Annuitant Birth Date: 09/24/1951
Issue Age/Sex: 50/F
Contract Number:
Annuity Payout Effective Date:
Plan Code:
Payout Option:
Contract Value:
Payment Frequency:
Number of Payments:
Guaranteed Amount:
Excess Interest:
Current Payment:
Cost Basis:
Exclusion Percentage: .
120
$888.13
$39.90
$928.03
$.00
.0000
Beneficiary Information
NAME
ALLOCATION
SSN
The contract value will be retained by the Company. Annuity income payments will be made on the
annuity payout effective date and continue until 120 such payments have been made.
The current payment will be the guaranteed amount plus excess interest. The Company reserves the right
to adjust the payments, however the current payment will never be less than the guaranteed amount.
Partial withdrawals will reduce the contract value as well as the future payments. Withdrawals are
subject to the provisions of the original contract. Penalties may apply.
In the event of the death of the Annuitant, the remaining payments will be made to the named
beneficiary(ies) at the time of death. 1fno beneficiary survives the Annuitant, the commuted value of
the remaining payments will be paid to the Executor or the Administrator of the Annuitant's estate.
We will send an annual statement to you on the payout anniversary each year.
www.horacemann.com
. Sank account information for Electronic Fund Transfer (EFT)
Please complete the lollowing if you wish to have your payment sent directly to your bank electronically for deposit.
Include a voided blank check or savings deposit slip to help us route your payments to your bank (if available through
yo,u ':1::\-~-:).
Bank name _p N c. 8 Q..J k
Routing # D'i'.3 ! 2. 1 ; 1, ;
Address Lf ,;1. tJ C e.. fI. I i~ Ir: ;)< f'
Street
~ Checking account
, - _' 0 Savings, aC~,o,unt
Account # dtO J t Q,/f~ofr,
~(H""..o I
City I State
/7nJl
ZIP
Please complete thi,s information for your request , I /J
Address I M o\J-,.)1a.'-r.! VI'EW '~IZ., Mec~~.NlcS!:)I.\,.{'C; , 0'11
Street I City I State
Date 01 birth g - ) i./ - 5 I Social Security # J.. 0 1- t.{ J.. . 19). 7 Telephone #(111-J
Mo/Day/Y ear Area code
1 70 5D
ZIP
t,97-597~
Phone #
Birth date
;[-1- ~ I
4-8-31./
Relationship to insured
~~~i~!f~
SS#
fi..f:fN
^f:t,.,)
'Contingent beneliciary(ies)
Full name/address
SS#
Birth date
Relationship to insured
Annuitant's signature
Spouse's sign tu e (il ap
Agent name
*Beneficiarv(ies) must be identified by name.
** Note: If contract was issued in Arizona, California, Idaho, Louisiana, Nevada, New Mexico,
Texas, Washington, or Wisconsin and the owner was married at the time of issue, the spouse's
signature is required.
Date f' - 7-0/
Date
Agent #
,'1 0g 9
Additional information
Horace Mann Life Insurance Company, located at P_O. Box 4657, Springfield, III. 62708-4657, underwrites the Annuity
Alternatives Contracts which are offered by Horace Mann Investors, Inc.
Horace mann.
Insuring Amllrica', Educational Community
_.hor.e.mann.com
www.rnc:hllvllryehlld.com
IA-004046 (2100)
Request for retirement income/settlement options
I, C Ci-t~,' Jo &AeeN
~ . . ~ -
C>""(\IiI.J(\ S~(;O
-SET/ ft !
i" '..
, request the following action(s) under contract #
CI),71;;f>I'III"'..\'Gf~""S) below to Indicate the option(s) you want. If you are requesting a combination 01 options, pl"",oe :
in~Uall:llthll cftIlIar amount or percentage on the reverse side under Additional Information, Proof of age is required
for any lifetime income options. U I 3 AM \ \: \ 3
Fixed lifetime income options100\ A G Other fixed income options
o Life only RECEIVED CC&R 0 Interest Income
o Life with a Period Certain ~ Fixed Period
Period Certain years (10, 15, 20) Period requested
o Joint and Survivor 0 Fixed Amount
_50% _66.67% _100% Amount requested $
Joint payee:
Name
Birth date
Social Security #
10
years
Sex
II you have money in the variable account and wish to choose a fixed option, the transfer of your value to the lixed
account and change in allocation to the fixed account will occur on the date we receive this form, unless otherwise
indicated.
Variable lifetime income options (indicate amount, or shares)
o Life only
o Life with a Period Certain
Period Certain: years (10,15, 20)
o Joint and Survivor
50% 66.67% 100%
Joint Payee:
Name
to HM Equity Fund
to HM Balanced Fund
to HM Income Fund
Sex
j L~;~}"
Birth date
Social Security #
,.,.,:;::.~",..,....-t'::Ifl';~~"""""'-""-'-
~~
If you have money in the fixed account and wish to choose a variable option, the transfer of your value to the variable
accounts indicated and change in allocation to the variable accounts will occur on the date we receive this form, unless
otherwise indicated.
Horace Mann requires that all retirement income/settlement options begin on the first of each month. (If a request is
received after the first, the effective date will become the first of the following month.) Please indicate the date you
would like your option to begin and the mode of payment.
Date option is to be effective ~ - I - 0 I .
Mode of payment: :Er monthly 0 quarterly 0 semi.annual 0 annual
Federal tax withholding information
You must elect whether or not to withhold federal income
tax from your payments. Pursuant to IRS rules and
regulations, we will withhold 20 percent of the taxable
portion of any payment from an Interest Income
option; a Fixed Period or Fixed Amount option if paid out
in less than 10 years (applies to TDAs and pension plans).
~I elect no withholding. )11 elect no withholding.
o I elect a flat amount of $ or_% be withheld. 0 I elect a flat amount of $ or_% be withheld.
If you do not indicate whether we are to withhold taxes from your payments, we will withhold 10% of the taxable
distribution except in situations as described above. , "'''
State tax withholding information
You must elect whether you want state taxes withheld
from your distribution in the following states:
Califomia, Georgia, Iowa, Kansas, Maine,
Massachusetts, Oregon, Oklahoma,
Vermont, and Virginia.
1 Mountain View Drive
Mechanicsburg, PA 17050
August 3, 2001
To Whom it May Concern,
When Richard F. Green designated a beneficiary of his tax shelter and retirement roll
over, upon his death the intended beneficiary was to be myself, Cathi Green, even upon
separation or divorce.
,::n: :ou'9
~r~
Cathi Green
ranm Companq
Plaza
15-0001
SiMPLE
r:~()th
.C~ Yes ;"": No
....x^j(
'._ ~1:r1qft.d mf m. m
4. jlllilh date iMMiDDNT) .7 ' ~'2j,:-: I
BNl'2A Member: Xy",s ~k
It .~:tS.lt .;;'0 LmYmQ~25L] ....
HI. Telephone ill1)0j]~5'17C
Stat<illl.m m 13 ZI F' code .1 J t: .sa
~t f'~I)~v{.)r.,c :.'nt d'
i.:-?Su,::,; a::l(~ ~;{:'-'l'
2. MallJiity diM (MM/DONYj
4. T ofai first Y.:Jar paynknt
~:.; Quarterly Monthiy
l/lO 1/9 List t);jJ 9~(;; H) it
",";"'--':.:':,':',-.:::-,^',"":''':: .,
.;l~~t$ ana sp,",cial "",,,,,,,ts
.... ~,.. ./r.. .. ....
IN; t;" \ P'1 .-,'10 ~i~.' ,II 1 ,}'>4'(
f'. P . ~;/I (-..,., . . r .., ,
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,ry.
I'AOjK({VV',
,
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'"
1--:'2f "L lI.. J e
2L Bif1t! data {t...~M!DD!YY)
a. Relaoorlship. ..,1) c.... 'f I....tA .?...
4. Blrtn dale (MM/DDi'N) '. .
f:bture t;"li:>; . F. ", ' ':~ : i: ';;
fle~lbie iump ~Hni ca~);
:,~'1Im$ prBn1iUrT S ,:,jl),
O' j9~ t;: '.
ro
O' '0
/0
s.......<) o.
,(:.
o. <,',
,~, ."
''-'
,"
f~ ".
,"
t),
,0
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'0
100 0,- .; Ol..! ,') l.._'('
'.
a~:':true ro tt:e best tJl m:; }...no'lt...'iedg~:'. 1 d;~hnCLVii(";'d90
. ~_ currant prOspecius(.?s for the Hor,:~c.:; HWHl L;j,,)
NlUtual Funds. For combination filled and
.Ulil'ill-'1\uurts and values provided by th..
lit of v_laMe aocount ($), ar.. variabl.. and
__~__2._:J- 0 to
(d<..1';~),t
.,. C q
._:,?{e if
Rej;Jlsterad prinCipal
...................".,......- -,
{r',C!'pp r,fh~{~ i..~;C
iL~A'1~~$Fti
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) 6 - ::::x/"). / 0
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. Z80601
HARRISBURG, PA 171Z8-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
JEFFREY R BOSWELL
BOSWEL L ET AL
PO BOX 741 \"'
HBG PAl17108
DATE
ESTATE OF
DA TE OF DEATH
FILE NUMBER
COUNTY
ACN
10-13-2003
GREEN
04-24-2001
21 01-0476
CUMBERLAND
101
'*
./
REV-1547 EX AFP (01-051
RICHARD
F
Allount RelliUed
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 ~
R'EV=is'4-j-E;f-AFP-COY=03Y-NO'ficE--OF-YNHEifiTANCi-TAX-APPRAiSEHENY-,--ALi-oWANCi-oi-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF GREEN RICHARD F FILE NO. 21 01-0476 ACN 101 DATE 10-13-2003
TAX RETURN WAS: (X) ACCEPTED AS FILED
) CHANGED
I~ an assessment was issued previously, lines 14, 15 and/or 1&, 17, 18 and 19 will
r~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
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. Mortgages/Notes Receivable (Schedule D)
5. Cash/Bank Deposits/Misc. 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
11,724.98
1,930.62
.00
(8)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adll. Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage 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)
(10)
3,822.19
3,193.53
(11)
(12)
(13)
(14)
NOTE:
.00
6,639.88
.00
.00
X 00 =
X 045 =
X 12 =
X 15 =
NOTE: To insure proper
credit to your account,
subllit the upper portion
of this forll with your
tax paYllent.
13,655.60
7.015 72
6,639.88
.00
6,639.88
(19)=
.00
298.79
.00
.00
298.79
rAX CREDITS:
, ~. ..-... .--,.-. l+J AMOUNT PAID
DATE NUHBER INTEREST/PEN PAID (-)
08-28-2003 CD002949 .00 298.79
08-28-2003 CD002950 26.49- 26.49
TOTAL TAX CREDIT 298.79
BALANCE OF TAX DUE .00
INTEREST AND PEN. .04
TOTAL DUE .04
. IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
~J
tJ..
STATUS REPORT UNDER RULE 6.12
Name of Decedent: Richard F. Green
Social Security No. 201-40-7517
Date of Death: April 24. 2001
Will No.
Register File No.
2001-00476
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.
2.
State whether administration of the estate is complete: Yes X
If the answer to #1 is No, state when the personal
representative reasonably believes that the administration
will be complete:
3. If the answer to #1 is Yes, state the following:
No
a. Did the personal representative file a final
account with the Court? Yes No--K-
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_
(Estate Settlement Agreement filed with the Court on September 3, 2003)
d. Copies of receipts, releases, joinders and
approvals of formal or information accounts may
be filed with the Clerk of the Orphans' Court
and may be attached to this report.
Date: October 17,2003
Signature: ~
Name: Jeffr . Boswell Es uire
Address: 315 North Front Street. Harrisburg. P A. 17101
Telephone: (717) 236-9377
Capacity:
_ Personal Representative
X Counsel
;..
",