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Home My WebLink About01-0825 Estate of Dorothy M. Crook also known as PETITION FOR PROBATE and GRANT OF LETTERS -ADMINISTRATION ~/-O/ - 'i'~ 6 C.T.A. No. To: Register of Wills for the , Deceased. County of Cumber land in the Social Security No. 1 88- 3 2 - 4 2 6 0 Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: y our petitioner(s),~~are 18 years of age or older.~~XXXXXXXXXXXXXXXXUed X"l1e last will of the above decedent dated June 2 0 , 19~ ~~re~~~names Allfirst Trust Company of PA, NA (successor to DaupHIn Deposit Bank and Trust Com an as Executor. Said named xecu or as renounce 1 s rlg t to act as such and have requested that Letters of Admin~st~ation CTA be ranted to th n 'gned, t e reSl uary it ~Rt~~s,Qt r~iat~Al,1E!ehth~"executor, etc.) Decendent was domiciled at death in Cumber land County, Pennsylvania, with her last fa,mily orJ;?rincipal residence at 824 Lisburn Road, Camp Hill Lower A~~en Township (list street, number and muncipality) Decendent, tl).en 97 years of age, died A ugus t 1 9 ,x~ ? 0 0 1 , ~ Communlty General Osteopathic Hospital, Harrisburg, PA Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted after execution of the will offered for probate; was not the victim of a killing and was never adjudicated incompetent: None Decendent at death owned property with estimated values as follows: (If domiciled in Pa.) All personal property (If not domiciled in Pa.) Personal property in Pennsylvania (If not domiciled in Pa.) Personal property in County Value of real estate in Pennsylvania situated as follows: $ 18,000.00 $ $ $ WHEREFORE, petitioner(s) respectfully request(s} tl).e probat~ of the last will and codicil(s) presented herewith and the grant of letters of admlnlstratlon, CTA (testamentary; administration c. La.; administration d. b.n.c. La.) theron. ~ '" 13/~ d?A~ ~~ Zane R. Meixner c::~ ~g 103 Tower View Drive c.O ~~ Butler, PA 16002 3~ ~'- ;'0 'i;i Q 00 <Ii 20886 OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA I S8 COUNTY OF CUMBERJ.AND J /7-5-6 The petitioner(s) above-named swearOO or affir~) 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 represen- tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. ~ ~H~ Sworn to or affirmed and subscribed ~ Vl before me this 28th day of . <::jane R. eixn ~. ~ ~s~ '. 001 ~ . 7&1 ( # ~AJ/V, ~ Mary /e. Lewis Register ~ No. 71-7001-825 Estate of DOROTHY M. CROOK , Deceased DECREE OF PROBATE AND GRANT OF LETTERS ADMINISTRATION C.T.A. AND NOW September 6 th }J~ 200,lin consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that the instrument(s) dated JUNE 20TH 1997 described therein be admitted to probate and filed of record as the last will of DOROTHY M. CROOK and Letters ADMINISTRATION C.T.A. are hereby granted to ZANE R. MEIXNER AND MERIBETH REED Probate, Letters, Etc. ......... Short Certificates(l) . . . . . . . . . . Renunciation... t2J......... x-Pages (5) JCP $ 50.00 $ 3.00 $ 10.00 $ 15.00 5.UU TOTAL _ $ ?~P.t;E?J1]l;>~:r. .f?:t.I11.~Q.QL .~;3.,: ~.q FEES (717)236-9577 Filed PHONE MAILED LETTERS TO ATTORNEY T'h;~ ;~ ''] cer6':,; ,;'at 61e inFormation here given is correctly copied from an original certificate of death duly filed with me as L(J~d R'~gislf3] TIlt original certificate wiJJ be forwarded to the State Vital Records Office for permanent filing. - WARNING: It is illegal to duplicate this copy by photostat or photograph. h'e fOJ' rhis certificate, $2.00 p 7620728 ab~~ .~ r~ Loca Registrar ~-r No. AUGD 2 2 20llt:-- ate 21-2001-825 S.I<3Rev.2117 - Of' DECEDENT If... _.l_, DOf(OTH Y COMMONWEALTH OF PENNSYlVANIA. OEPARTMENT OF HEALTH. VITAL RECOROS CERTIFICATE OF DEATH .. M. C t€OO K. SEX F SWfFllf~ SOCIAl. SECUR''''' NUMBER .. Ia'? -.3.2 - 4.21.:,0 AGECl__" UNDER'_ 9'7.... - o.v. UNDER . 0J0f -1- DATE Of' lIIRTH tUonlh. Day, ...., lIIIlTHI'lACE (Coly.... 1Ilf1;/sif~ . COlIN"" OF llEArH hin ~,o RACE._-.-._..... ~ . ... WH rnt SURvI1I1NG SI'OUsE (M... QIWle "'-'en ftIlmeJ DkI - ...... __1 l7ill :"-::-:::.. :THER'S"Et"._._SurM; L.LEV /9~-'omMtuflV~J9iTJliZS'&le& AIJ/JfYI.Jl/f.j PlACEOf'lllSPO$tTiiii._..~ c~ LllCRlOH.~ -.lillC<lcfa ::E-:;-sr ~fj(/ft: C~lTJt. tlO. J1W.ll4<J/.t-~tJJ!G I/i#f _AND_l!SOf'~ I 1fiS~. P4 Do. 4), o.tUILU!. 14/IJ.m0-f'rL J7/ ..a lICENSE_R ...... _. ~ . . \1M CASE REFERRED TO MElltCAL Ex.w,~ ..... 0 Hoe!:! ... , Appf'uimafe '-- :..... and.... I , I PART.: OoIlar...-_......-.IO_.llul ...~..",.~-giwan..PART,. f : L WERE AUlOPSY F'NDINGS -...s&.E PRIOR 10 C<lMPt.ErIoH OF CAuSE OF llEArH1 DUE lOltlA ASA CONsEOUENCE OF}: DUE 10 lOR AS A CONsEOUENCE OF): o? ..:? I c:yOO/ ......HER OF OE.<rH Hog .....0 HoD - ~ - 0 - 0 -- DATE OF INJURY ,-. Day._, TIUE OF INJURY INJURY", lI'oORK1 DElSCRlBE HOW IHJURV OCClIRAED. "'-'-..ov-. ..... 0 HoD .... _. ... CMTlAEIloo.... only DnaI 'CMT~PHY_(Ph-C8AI}ong--d___..._.........onouncoct"""'_c"""-n""231 T...._ot...................__............auMl.,........_................... ........ '" ........ ... ......... ......... ... Coutd '* IN dIIenn.ned .JIIIIONOUHcaHo AND CERTWYINO PHYSICIAN IPhvscan boch Pfonounctng oeath oind C4tf1IfyIng IOcause of death) To..._ot"'Y....wtodga.___....._. do.., .""-......._10...._"............................................ ... 'III!OtCAL EllAlIlHEIIICOROHER On........1o al......'.....1an 'ndlCM"nv"UV"iaft.'n my apln",n. d..... ac.u".d "'Ila I...... d..., and p..... and duo.. Ill. .au"""nd ......_......ed................................................................................................. . 318. ~E TAAA'S SIGNATURE AND NUMBER ~/ otl/i/ I ... ~ . .. 21-2001-825 LAST WILL AND TESTAMENT OF DOROTHY M. CROOK I, DOROTHY M. CROOK, now of Camp Hill, Cumberland County, Pennsylvania, declare this to be my Last Will and Testament and hereby revoke all prior Wills and Codicils made by me. ITEM I. I direct that all of my just debts and funeral expenses, including the cost of my gravemarker, if any, shall be paid for from my residuary estate as soon as practical after my decease as an administrative expense of my estate. ITEM II. I give and devise all of my estate of every nature and wherever situate as follows: A. To my nephew, ZANE R. MEIXNER, and his wife, GERTRUDE MEIXNER, or the survivor of them or their issue, per stirpes, I give my grandparents' Chinese chair and twenty (20%) percent of the residue of my estate. I direct that the cost of shipping the chair to the beneficiaries shall be an administrative expense of and be paid by my estate. B. The remainder of my estate I give to my grandniece, MERIBETH REED, or her issue, per stirpes. ITEM ill. If any income or principal shall be payable to any person who shall be under the age of twenty-one (21) or who shall be incapacitated for any reason, my personal representative, as trustee, shall hold such income and principal for such beneficiary until the age of twenty-one (21) ..tY~ ~-rJy~ Dorothy M. Croo - . .. or during incapacity and shall be entitled to apply such income and principal to the health, maintenance, support and education of such person without the appointment of any guardian or committee or any authority of court, and shall be entitled to make direct application hereunder or to make application by payment thereof to the parent or other person in charge of such person, or to his or her guardian or to a custodian under the Uniform Transfers to Minors Act. Any remaining income and principal to which such person shall be entitled shall be paid and distributed to such person upon attaining the age of twenty-one (21) or upon the termination of incapacity. ITEM IV. I appoint DAUPHIN DEPOSIT BANK AND TRUST CaMP ANY, Harrisburg, Pennsylvania, Executor of this my Last Will and Testament. No bond shall be required by my personal representative in any jurisdiction. ITEM V. In addition to the powers given by law to my personal representative( s) and trustee( s) [hereinafter fiduciaries] in the administration of my estate and of any trust( s) created herein, they shall have the following discretionary powers applicable to all real and personal property held by them, including property held for minors, effective without court order until actual distribution. A. To retain any property owned by me at my death and to invest any funds held by them in any stocks, bonds, notes or other securities or property, real or personal, including common trust funds, mutual funds and money market deposit accounts operated or offered by my corporate trustee, if any, or any affiliate of it. B. To sell or otherwise dispose of any property, real or personal, at any time forming a part of my estate or the trust estate, for cash or upon credit, in such manner and on such terms as d~~,~<:.. Dorothy M. Crook 2 .. they see fit, and no one dealing with the fiduciaries shall be bound to see to the application of any monies paid. C. To manage, operate, repair, improve, mortgage or lease for any tenn [even if beyond the duration of the trust(s)] any real estate at any time held or owned by them as fiduciaries. D. To hold investments in the name ofa nominee and exercise and dispose of Warrants. E. To engage in litigation and compromise, arbitrate or abandon claims and property. F. To conduct any business in which I am engaged or in which I have an interest at the time of my death for such period as the fiduciaries deem advisable, with the power to borrow money and to pledge the assets of the business and to do all other acts which I, in my lifetime, could have done, or to delegate such powers to a partner, manager or employee without liability for any loss occurring therein. G. To allocate items of receipt or disbursement between principal and income as the fiduciaries deem equitable regardless of the character given such items by law; to distribute in cash or kind or partly in each at valuations fixed by the fiduciaries. H. To borrow money, including the right to borrow from any corporate trustee, if any, and to mortgage or pledge as security or to hold its own stock if a corporate trustee. I. To join in any merger, reorganization, voting trust plan or other concerted action of security holders, and to delegate discretionary duties with respect thereto. J. Should the principal of any trust herein provided for be or become too small in trustee's opinion so as to make establishment or continuance of the trust inadvisable, my trustee(s) may make immediate distribution of the then remaining principal and any accumulated or undistributed income df?~ ??, - (!~ Dorothy M. Crook 3 'A, outright to the person or persons and in the proportion they are then entitled to income. Upon such termination, the rights of all beneficiary(ies) who might otherwise have an interest as succeeding income beneficiary(ies) or in remainder shall cease. K. In general, to exercise all powers in the management of the assets of my estate or the trust estate which any individual could exercise in the management of similar property owned in his own right, upon such terms and conditions as the fiduciaries may deem best, and to execute and deliver all instruments and to do all acts which the fiduciaries may deem necessary or proper to carry out the purposes of this will or any trust(s) created herein. L. To apply income or principal to which any beneficiary is entitled, directly for his or her comfort, maintenance and support, should the fiduciaries deem such beneficiary incapable of receiving the same by reason of age, illness, infirmity or incapacity, or to pay the same to such person or persons as the fiduciaries select to disburse it, whose receipt shall be a complete acquittance therefore without the intervention of any guardian. M. To assume continuance of the status of any beneficiary with reference to death, marriage, divorce, illness, incapacity or other change in the absence of information deemed reliable without liability for disbursements made on such assumptions. N. All principal and income shall, until actual distribution to any beneficiary, be free of the debts, contracts, alienations and anticipations of any beneficiary, and the same may not be liable for any levy, attachment, execution or sequestration while in the hands of any beneficiary, and the same may not be liable for any levy, attachment, execution or sequestration while in the hands of any fiduciaries. ~~~~~~- Dorothy M. Crook 4 .~ of qu~ IN WITNESS WHEREOF, I have hereunto set my hand and seal this -<O~day ,1997. U~~7;}l"~ Dorothy M. Crook The preceding instrument, consisting of this and four other typewritten pages, identified by the signature of the testatrix, as on the day and date thereof signed, published and declared by Dorothy M. Crook, the testatrix therein named, as and for her last Will, in the presence of us, who, at her request, in her presence and in the presence of each other, subscribed our names as witnesses hereto. bf'lJ'c l1.kQ~~-<-tfA 1711~ .::26 a N. $,..--J U/,,~L(r:iOAr cZ t ?~d'( 5 . ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA: : SS. COUNTY OF DAUPHIN I, DOROTHY M. CROOK, testatrix whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my last Will, that I signed it willingly, and that I signed it as my free and voluntary act for the purposes therein expressed. ~~.-{l~~ Dorothy M. Crook Sworn or affirmeMnd acknowledged before me, by Dorothy M. Crook, testatrix, this Z O.p., day of ~ I'lL , 1997. ~~ ULA% Notary '),~blic My Commission Expires: NOT AAIAL SEAL HOLLY S. KIRK Notary Public Harrisburg, Dauphin County My Commission Expires Feb. 15, 1999 AFFIDA VIT COMMONWEALTH OF PENNSYLVANIA: : SS. COUNTY OF DAUPHIN We, CCor Q d ald. /a , the witnesses whose name are signe to the attached or foregoing instrument, being duly q lified according to law, do depose and say that we were present and saw testatrix sign and execute the instrument as her last Will; that she signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the testatrix signed the Will as witnesses; and that to the best of our knowledge the testatrix was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. 1997. Sworn to and subscribed before me this :{O*' day of C) tr iL/_ - CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: Dorothy M. Crook Date of Death: August 19,2001 Administration No.: 21-01-0825 To the Register: E: I certify that notice of estate administration required by Rule 5.6(a) of the Orphans' Court Rules was given to the following beneficiaries set forth on the attached list on September 17, 2001. ard L. Placey, Esquire Attorney for the Estate 3631 North Front Street Harrisburg, P A 17110 (717)236-9577 Date: September 17,2001 - ESTATE OF DOROTHY M. CROOK NOTICE GIVEN TO: Zane R. and Gertrude Meixner 103 Tower View Drive Butler, P A 16002 Meribeth Reed 19132 Romans Way Gaithersburg, MD 20886 - AUG-27-01 '4:04 PM PLACEY-WRIGHT 717 236 0843 P.02 Register of Wills of Cumberland County, Pennsylvania RENUNCIATION AND REQUEST Estate of Dorothy M. Crook, Deceased No. 21-2001-825 The undersigned, Allfirst Trost Company of Pennsylvania, NA, successor to Dauphin Deposit Bank and Trust Company, Executor named in the Will of the captioned Decedent dated June 20, 1997, hereby renounces its right to administer the estate as Executor and respectfully requests that Letters of Administration, CT A, be issued to the residuary beneficiaries under Decedent's Will. Zane R. Meixner and Meribeth Reed. WITNESS, my hand this .2B~ay of August, 2001. Sworn to and Subscribed before me this 2..5 'f4-day of August, 2001. (x:Q..e~/k/Jl-Ci ~.' )1{.LLa..J Notary Public My Commission Expires: Netarial Seal Deanna L. Wells, Notary Public Harrisburg. Dauphin County My CommIssiOn Expires Dec. 6, 2004 Memb8f. PeMlylv8nla ~"iIn 01 NoWie9 - - Register of Wills of Cumberland County, Pennsylvania RENUNCIATION AND REQUEST Estate of Dorothy M. Crook, Deceased No. 21-2001-825 The undersigned, one of the residuary beneficiaries under the Will of the captioned Decedent dated June 20, 1997, hereby renounces her right to administer the estate as Administratrix, CT A, and respectfully requests that Letters of Administration, CT A, be issued to the other residuary beneficiaries under the Will, Zane R. Meixner and Meribeth Reed. WITNESS, my hand this ~ day of August, 2001. ~~~ Witness e de Meixner 1 3 Tower View Drive Butler, P A 16002 ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA : : SS. COUNTY OF On this, the ,J I day of ~-f- ,2001, before me, the undersigned officer, personally appeared Gertrude M lxner, known to me (or satisfactorily proven), to be the person whose name is subscribed to the within instrument, and acknowledged that she executed the same for the purposes therein contained. IN WITNESS WHEREOF, I have hereunto set my hand and official seal. ~ l tt--- ~otary Public My Co -r Notarial Seal Terri J. Hosack, Notary Public Butler, Butler County My Commission Expires Oct. 4, 2004 Member, Pennsylvania Association ot Notanes - t i'" ~ ~.~.. It t.!'.~.:~,:::'';< p,r70 i~.,il " ., Ie i t ~ \ ~ -.~~. r :l: ! ;,,; Iml ~.I il t<:: i ~i.. i. ia' 0 I ui I UL ,.~I,'~~,~J l~ ..~~~ :t.'->;4";~'\~";,~~, -:> t~\~~ "'".i\j~'::<"~t.;~",,~~ :; ~';,';f~4~ ~ r\:!,.'-. > c, /' ~ u:l ~ o (/)::I: d~ ~O ~u o ~><~ ~E-<~ E-<5=:: (/) ...J - (j OOif)M ~UU-l8 ~(/)f'- (/)~ ;:J- - 0...... ~ ::r::....... U-lHE-<p.. H ~ ~ ~ . ~ ;:J ~ u~o(/) >< U::l ~ U-l ~ <: z <: :::Euou - - , ~ U. > <.-";J ~ ~ \. ~ 1 ('.I s ..... IS! I'~I (~I ,f- ~I ..... IS! ..... ..... r'l r'l 10 ~ W ~ :t Wi' o 3 ~ ~ ~ ~ !z ~ ~ ~ 0 ~ 1Oe:~ as ~ ;X:.~ "-- o::D:W ~ 0 0 a.. U ~ ~ g :S ~ ffi ~ r'l![l 0:: 0:: <( I 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 PLACEY RICHARD L ESQ 3631 NORTH FRONT STREET HARRISBURG, PA 17110-1533 hU____ fold ESTATE INFORMATION: SSN: 188-32-4260 FILE NUMBER: 21-2001- 0825 DECEDENT NAME: CROOK DOROTHY M DATE OF PAYMENT: 11/13/2001 POSTMARK DATE: 11/08/2001 COUNTY: CUMBERLAND DATE OF DEATH: 08/19/2001 NO. CD 000515 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $10,000.00 I I I I I I I I TOTAL AMOUNT PAID: REMARKS: RICHARD L PLACEY ESQUIRE CHECK# NO # SEAL INITIALS: AC RECEIVED BY: $10,000.00 MARY C. LEWIS REGISTER OF WILLS REGISTER OF' WILLS COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT PLACEY RICHARD L ESQ 3631 NORTH FRONT STREET HARRISBURG, PA 17110-1533 -------- fold ESTATE INFORMATION: SSN: 188-32-4260 FILE NUMBER: 2101-0825 DECEDENT NAME: CROOK DOROTHY M DA TE OF PAYMENT: 04/15/2002 POSTMARK DATE: 04/12/2002 COUNTY: CUMBERLAND DATE OF DEATH: 08/19/2001 REMARKS: RICHARD PLACEY ESQUIRE CHECK#1537 SEAL ACN ASSESSMENT CONTROL NUMBER 101 TOTAL AMOUNT PAID: INITIALS: AC RECEIVED BY: REGISTER OF WILLS REV-1162 EX(11-96) NO. CD 001066 MARY C. LEWIS REGISTER OF WILLS AMOUNT $1,637.07 $1,637.07 ~ . . ~"'~ ~ rr .. i.... I. , ...~,.~'~~!~.~; . ", I" t., ~,',,:(, : ",".,," " ,"\j (1,1 131 (.'1 - -ca ::E tn tn as - () ~ u:: 1'......... l~..:.l r' ,j Lr. -;.... 6: ~-:::: N P ".. :,.~ 1.._.... ~~"'.,.., I'ill I, ' l") l") If) o s: et: ~ ~ ~ ~ ~ ~ z ~ I- ~ ~ p ~ [g GS ~ ~ ~ ~ It 0 CL ~ ~ Z . U <( _ ~ -< C') :J ~ ((J Cl ~ l'I~ a:: 4: :c . u) ~ ::> o ::r: E-t p::;~ ::>p::; Ooet:M U::>r- U)~Qlo HE-tu)f' HZ r- H::>~ S:O~~ UOP-. ~ ::r: O~E-t .. P::;oet:P::;~ ~H::>...:I E-tP::;OUJ u)~UH HI!l~~ l')~Z~ ~::>O() P::;U .. o E- ~ ~ ~ ~ ~ ~ ~ ~ ~ <-- /7-6-6 ~ 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 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 05-27-2002 CROOK 08-19-2001 21 01-0825 CUMBERLAND 101 RICHARD L PLACEY PLACEY & WRIGHT 3631 N FRONT ST HBG '02 l'l,4Y 31 PI :tSo ESQ L P A l1(rJ.'n Allount Rellitted * REY-1541 EX AFP [01-02) DOROTHY M MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE .. RETAIN LOWER PORTION FOR YOUR RECORDS ~ REV=is4-j-ix--AFP-('OY=0'2Y-NOYiCi--OF-YNHiififANCE-YAX-APPRA-isiMENT~--AL1-oWANCE-OR----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF CROOK DOROTHY M FILE NO. 21 01-0825 ACN 101 DATE 05-27-2002 TAX RETURN WAS: (X) ACCEPTED AS FILED 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 ( ) CHANGED (1) (2) (3) (4) U;) (6) (7) .00 .00 .00 .00 21.768.50 .00 69.598.14 (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 I~ an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will re~lect ~igures that include the total o~ ALL returns assessed to date. ASSESSMENT OF TAX: 15. Allount of line 14 at Spousal rate (15) 16. Allount of line 14 taxable at lineal/Class A rate (16) 17. Allount of line 14 at Sibling rate (17) 18. Allount of line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due TAX C ITS: I"AT DATE 11-08-2001 04-12-2002 NOTE: Kt:l;t:.L1" I NUHBER CD000515 CDOOI066 (+J INTEREST/PEN PAID (-) 526.32 .00 (9) (10) 8,555.38 00 = 045 = 12 = 15 = (19)= NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent. 91,366.64 10 .277 54 81,089.10 .00 81,089.10 .00 .00 .00 12,163.37 12,163.37 12,163.39 .02CR .00 .02CR . 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.) 1.722.16 (11) (12) (13) (14) .00 X .00 X .00 X 81,089.10 X AMOUNT PAID 10,000.00 1,637.07 TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE J- PLEASE FILE THIS REPORT WITHIN TWO YEARS OF DATE OF DEATH REGARDLESS OF THE STATUS OF THE ESTATE. IF ESTATE IS NOT COMPLETED, FILE a 6.12 FORM YEARLY UNTIL COMPLETION STATUS REPORT UNDER RULE 6.12 Name of Decedent: Date of Death: Estate No.: Dorothy M. Crook August 19, 2001 21-01-0825 . . Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: Yes X No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No. 1 is yes, state the following: A. Did the personal representative file a final account with the court? ~s ~ X B. The separate Orphans' Court No. (if any) for the personal representative's account is: (Not Applicable in Dauphin County) C. Did the personal representative state an account informally to the parties in interest? Yes X No D. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. (date) Date: 7 / 2 6 / 0 2 Name (Please type or print) 3631 N. Front street Harrisburg, PA 17110-1533 Address (MAH:nntl AM3) (717)236-9577 Telephone No. Capacity: Personal Representative R.W. - 56 X Counsel for Personal Representative - .... . -, ..- .-- ~~! .r) '-) \.. IN RE: DOROTHY M. CROOK TRUST UNDER AGREEMENT IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION APPROVAL OF ACCOUNT. RELEASE AND INDEMNIFICATION DOROTHYM. CROOK TRUST UNDER AGREEMENT The undersigned is one of the designated beneficiaries of the Dorothy M. Crook Trust Under Agreement with Allfirst Trust Company of P A, NA, Successor to Dauphin Deposit Bank and Trust Company, Trustee. Allfirst Trust Company ofP A, NA ("Trustee"), is willing to make distribution ofthe assets of the trust without the formality of a court accounting upon the receipt of a proper release, receipt and indemnification, which it is the purpose of this document to provide. In consideration of the willingness of the Trustee to make distribution without the formality ofa court accounting and agreeing to be legally bound hereby, the undersigned does hereby: 1. Waive the filing of an account of the administration of the trust in any court; 2. Declare that the undersigned has examined the attached informal Statement of Account of the Trustee; accepts and approves it with the same force and effect as if it had been prepared and filed with, audited, adjudicated and confrrmed absolutely by a court of competent jurisdiction; and as if the balance of principal and income had been awarded by the court in accordance with the Statement; 3. Warrant that the undersigned is one of the beneficiaries named in the First Amendment to the trust instrument dated July 3, 1997 and is entitled to receive the distribution therein set forth; - "r"'" f' 4. Absolutely and irrevocably releases and discharges the Trustee, its successors and assigns, of and from any and all actions, liabilities, claims and demands relating in any way to the administration of the trust and distribution in accordance with the Statement of Account. 5. Agree to indemnify and hold harmless the Trustee, its successors and assigns, from and against any claims, liabilities, loss or expenses (including costs and counsel fees) arising from any cause whatsoever which the Trustee may incur as a result of the administration of the trust and distribution in accordance with this document and to refund to the Trustee any portion of the distribution of the undersigned which exceeds the amount of the undersigned's share as the Trustee finally determines. , 2002. ~~6Q,~~ Merib Reed. ~------ 11-IOMAS C. FAHRES NOTARY PUBUC MONTGOMERY COUNTY, MO Com. Expires 07-01-04 - .J --..' IN RE: DOROTHY M. CROOK TRUST UNDER AGREEMENT IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DNISION APPROVAL OF ACCOUNT. RELEASE AND INDEMNIFICATION DOROTHY M. CROOK TRUST UNDER AGREEMENT The undersigned is one of the designated beneficiaries of the Dorothy M. Crook Trust Under Agreement with Allfirst Trust Company ofP A, NA, Successor to Dauphin Deposit Bank and Trust Company, Trustee. Allfirst Trust Company ofPA, NA ("Trustee"), is willing to make distribution of the assets of the trust without the formality of a court accounting upon the receipt of a proper release, receipt and indemnification, which it is the purpose of this document to provide. In consideration of the willingness of the Trustee to make distribution without the formality of a court accounting and agreeing to be legally bound hereby, the undersigned does hereby: 1. Waive the filing of an account of the administration of the trust in any court; 2. Declare that the undersigned has examined the attached informal Statement of Account of the Trustee; accepts and approves it with the same force and effect as ifit had been prepared and filed with, audited, adjudicated and confirmed absolutely by a court of competent jurisdiction; and as iftne balance ofprincipai and income had been awarded by the court in accordance with the Statement; 3. Warrant that the undersigned is one of the beneficiaries named in the First Amendment to the trust instrument dated July 3, 1997 and is entitled to receive the distribution therein set forth; . j ....-.", . . 4. Absolutely and irrevocably releases and discharges the Trustee, its successors and assigns, of and from any and all actions, liabilities, claims and demands relating in any way to the administration of the trust and distribution in accordance with the Statement of Account. 5. Agree to indemnify and hold harmless the Trustee, its successors and assigns, from and against any claims, liabilities, loss or expenses (including costs and counsel fees) arising from any cause whatsoever which the Trustee may incur as a result of the administration of the trust and distribution in accordance with this document and to refund to the Trustee any portion of the distribution of the undersigned which exceeds the amount of the undersigned's share as the Trustee finally determines. IN WITNESS WHEREOF, intending to be legally bound, the undersigned has executed this document this ~ a. day of ~ <J \ Y ,2002. D\\\,~~~Q~..... tness ~ (!a/lrjJY~ (SEAL) Zane R. Mei er . . INRE: ESTATEOF DOROTHY M. CROOK, DECEASED IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION o 1 - ~.;ls APPROVAL OF ACCOUNT. RELEASE AND INDEMNIFICATION ESTATE OF DOROTHY M. CROOK. DECEASED The undersigned is one of the residuary beneficiaries of the Estate of Dorothy M. Crook, Deceased. Zane R Meixner and Meribeth Reed, Co-Executors of the Estate of Dorothy M. Crook (hereinafter "Personal Representatives"), are willing to make distribution of the assets of the estate without the formality of a court accounting upon the receipt of a proper release, receipt and indemnification, which it is the purpose of this docwnent to provide. In consideration of the willingness of the Personal Representatives to make distribution without the formality of a court accounting and agreeing to be legally bound hereby, the undersigned does hereby: 1. Waive the filing of an account of the administration of the estate in any court; 2. Declare that the undersigned has examined the attached informal Statement of Account of the Personal Representatives; accepts and approves it with the same force and effect as if it had been prepared and filed with, audited, adjudicated and confirmed absolutely by a cowt of competent jurisdiction; and as if the balance of principal and income had been awarded by the court in accordance with the Statement; 3. Warrant that the undersigned is one of the residuary beneficiaries named in the infonna! Statement of Account and is entitled to receive the distribution therein set forth; . . 4. Absolutely and irrevocably releases and discharges the estate, the Personal Representatives and Placey & Wright, attorneys for the estate, their respective heirs, personal representatives, successors and assigns, of and from any and all actions, liabilities, claims and demands relating in any way to the administration of the estate and distribution in accordance with the informal Statement of Account. 5. Agree to indemnifY and hold harmless the Personal Representatives and their personal representatives, successors and assigns, :from and against any claims, liabilities, loss or expenses (including costs and counsel fees) arising from any cause whatsoever which the Personal Representatives may incur as a result of the administration of the estate and distribution in accordance with this docwnent and to refimd to the Personal Representatives any portion of the distribution of the undersigned which exceeds the amount of the undersigned's share as the Personal Representatives finally determine. IN WTINESS WHEREOF, intending to be legally bound, the beneficiary has executed this document this fIde. day of h ,2002. ~)qi~~ ~ ~~ #? h~ (SEAL) Zane R. Meixner and Ge de M ixner . . INRE: ESTATEOF DOROTHY M. CROOK, DECEASED IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DNISION APPROVAL OF ACCOUNT. RELEASE AND INDEMNIFICATION ESTATE OF DOROTHY M. CROOK. DECEASED The undersigned is one of the residumy beneficiaries of the Estate of Dorothy M. Crook, Deceased. Zane R Meixner and Meribeth Reed, Co-Executors of the Estate of Dorothy M. Crook (hereinafter ''Personal Representatives"), are willing to make distribution of the assets of the estate without the formality of a court accounting upon the receipt of a proper release, receipt and indemnification, which it is the pwpose of this docwnent to provide. In consideration of the willingness of the Personal Representatives to make distribution without the formality of a court accounting and agreeing to be legally bound hereby, the undersigned does hereby: 1. Waive the filing of an account of the administration of the estate in any court; 2. Declare that the undersigned has examined the attached informal Statement of Account of the Personal Representatives; accepts and approves it with the same force and effect as if it had been prepared and filed with, audited, adjudicated and confirmed absolutely by a court of competent jurisdiction; and as if the balance of principal and income had been awarded by the court in accordance with the Statement; 3. Warrant that the undersigned is one of the residumy beneficiaries named in the infonnal Statement of Account and is entitled to receive the distribution therein set forth; , . 4. Absolutely and llrevocably releases and discharges the estate, the Personal Representatives and Placey & Wright, attorneys for the estate, their respective heirs, personal representatives, successors and assigns, of and from any and all actions, liabilities, claims and demands relating in any way to the administration of the estate and distribution in accordance with the informal Statement of Account. 5. Agree to indemnify and hold hannless the Personal Representatives and their personal representatives, successors and assigns, from and against any claims, liabilities, loss or expenses (including costs and counsel fees) arising from any cause whatsoever which the Personal Representatives may incur as a result of the administration of the estate and distribution in accordance with this document and to refund to the Personal Representatives any portion of the distribution of the undersigned which exceeds the amount of the undersigned's share as the Personal Representatives finally determine. . 2002. SEAL) - ----....:...... ~~. ...-'-, THOMAS C. FAHRES NOTARY PUBLIO MONTGOMERY COUNTY, MD Com. Expires 07-01-04 , . ESTATE OF DOROTHY M. CROOK Statement of Account Stated from Seotember 17. 2001 to Mav 29. 2002 ASSETS 1. AlUirst Checking Account 0024712752 $ 18,705.19 2. ING Reliastar - July and August annuity payments 271.80 3. P A Blue Shield - reimbursement 9.64 4. United Life for Jackson Life - August and September benefits 378.36 5. Verizon - credit refund 12.31 6. TV Guide - credit refund 37.51 7. Penn Treaty Network - refund unused premium 653.36 8. The Woods - refund security deposit/interest 1,473.28 9. United Security Assurance - premium refund 884.58 10. United Security Assurance-payment of claim 150.03 II. Penn Treaty Network - payment of claim 180.00 12. IRS - refund 2001 1040 1.013.40 Total Assets $23. 769.4~ . . 09/27/01 09/27/01 09/27/01 09/27/01 09/27/01 09/27/01 10/19/01 11/06/01 11/08/01 11/08/01 11/20/01 04/12/02 04/12/02 04/12/02 04/12/02 W. Orville Kimmel Funeral Home West Shore EMS - debt of decedent Verizon - debt of decedent SouthCentral EMS, Inc. - debt of decedent Metropolitan Medical, Inc. - debt of decedent Homeland Center - debt of decedent Community Lifeteam, Inc. - debt of decedent Patriot-News Company - estate advertising P A Public School Retirement System - reimbursement August direct deposit Cumberland County Register of Wills, Agent - payment on account ofPA inheritance tax 10,000.00 The Woods - debt of decedent 240.00 Meribeth Reed - reimbursement mileage 606.77 Meribeth Reed - reimbursement phone 118.66 Cumberland County Register of Wills - filing P A inheritance tax return Cumberland County Register of Wills - additional P A inheritance tax due Placey & Wright - reimbursement costs advanced Cumberland Co. Reg. of Wills - probate - $83.00 Cumberland Law Joumal- est. adv. - 75.00 Short Certificates 6.00 Reproduction _ 14.20 Placey & Wright - attorney fees EXPENSES AND DEBTS $ 300.00 37.20 56.13 75.00 48.00 161.42 339.00 91.38 765.41 15.00 1,637.07 178.20 7.000.00 Total Expenses and Debts $ 21.669.24 2 . . .. RECAPITULATION Assets $23,769.46 LESS: Expenses and Debts 21.669.24 BALANCE FOR DISTRIBUTION S 2,1 00.2~ PROPOSED DISTRIBUTION BALANCE FOR DISTRIBUTION (All in Cash) S 2.100.22 Zane R. Meixner and Gertrude Meixner - 20% Residue $ 420.04 Meribeth Reed - 80% Residue $ 1,680.18 We, Zane R. Meixner and Meribeth Reed, Co-Executors of the Estate of Dorothy M. Crook, verify that the foregoing is a true and correct Statement of Account. z~ d\./'(~ Zane R. Meixner, Co-Executor Dated: / / M- d.. tJ &1 2.. "1&'1/02- 3 COMMONWEALTH OF PENNSYlVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT DECEDENT'S NAME (lAST, FIRST, AND MIDDLE INIT1Al.) I- Z CROOK, Dorothy M. ~ DATE OF DEATH (MM-OD-YEAR) DATE OF BIRTH (MM-DD-YEAR) ~ August 19, 2001 May 17, 1904 W (IF APPLICABLE) SURVIVING SPOUSE'S NAME (lAST, FIRST, AND MIDDLE INIT1Al.) C ~ 3l:::!rn uO::3l:: wa..u xOO uo::~ a..lD a.. ~ [iJ 1. Original Return D 4. Umited Estate Ii] 6. Decedent Died Testate (AIIach CllJlY 01 WI) D 9. Litigation Proceeds Received D 2. Supplemental Return o 4a. Future Interest Compromise (dale 01 dea1II aller 12-12-82) o 7. Oe<:edent Maintained a Living Trust (AIIach CllJlY 01 Trusl) o 10. Spousal Poverty Credit (dale 01 dea1II ~ 12-31-91 and 14.95) OFFICIAL USE ONLY /"'-..6'- 6 FILE NUMBER 21_01 o 8 2 5 - NUI.IlER- - - COUHTY CODE YEAR SOCIAL SECURITY NUMBER 188 - 32 4260 THIS RETURN MUST BE RLEC IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER o 3. Remainder Refum (dale 01 death prior m 12-1J:a2) o 5. Federal Estate Tax Return Required 8. Total NWnber of Safe Deposit Boxes o 11. Election 10 tax under Sec. 9113{A) (AlIach Sell 0) . . z o ~ ~ ::) Q. ::E o o g NAME Richard L. Placey, Esquire FIRM NAME (If AppIcabIel. Place & wri ht TELEPHONE NUMBER (717)236-9577 COMPLETE MAILING ADDRESS 3631 North Front street Harrisburg, PA 17110-1533 (1) .00 (2) .00 (3) .00 (4) .00 (5) 21,768.50 (6) .00 (7) 69,598.14 (8) (9) 8,555.38 (10) . 1,722.16 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or So/e-Proprielorship 4. Mortgages & Ncites Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Oovned Property (Schedule F) D Separate Billing Requested 7. Inter-VIVOS Transfers & Miscellaneous Non-Probate Property (Schedule G or L) 8. Total Gross Assets (total Unes 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) 10. Debts of Decedent, MoI1gage Uabililies, & Uens (Schedule I) 11. Total Deductions (Iotal Unes 9 & 10) 12. Net Value of Estate (Une 8 minus Une 11) 13. Charitable and Governmental BequestslSec 9113 Trusts for which an eIedion 10 tax has not been made (Schedule J) 14. Net Value Subject to Tax (Une 12 minus Una 13) z o 5 ::) I- 0: c( o W 0: SEE INSTRUCTIONS ON REVERSE SIDE FOR APPlICABLE RATES 15. Amount of Line 14 taxable at the spolISlll tax rate, or transfers under Sec. 9116 (a)(l.2) 16. Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling late 18. Amount of Line 14 taxable at collateral rate 19_ Tax Due 81,089.10 x .0 _ (15) x _0 _ (16) x .12 (17) x .15 (18) CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ....-r .;....., . OFFICiAl USE ONLY ,...:: r::.::i ',----q : ) '.....'_\ t.....n 91,366.64 (11) (12) (13) 10,277.54 81,089.10 '.00 (14) 81,089.10 (19) .00 .00 .00 12,163.37 12,163.37 m~..''''", '* COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER 21-01-0825 ESTATE OF DOROTHY M. CROOK 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. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11 . 12. 13. VALUE AT DATE OF DEATH DESCRIPTION Allfirst Checking Account No. 0024712752 Principal - $17,744.85 Interest - $ .49 (See bank letter attached) 17,745.34 ING ReliaStar - July and August annuity payments 271.80 PA Blue Shield - reimbursement 9.64 United Life for Jackson Life - August benefits 189.18 Verizon - credit refund 12.31 23.98 TV Guide - credit refund Penn Treaty Network - refund unused premium 653.36 The Woods - refund security deposit/interest 1,473.28 United Security Assurance - premium refund 884.58 United Security Assurance - payment of claim 150.03 Penn Treaty Netowork - payment of claim 180.00 Household Goods 175.00 Miscellaneous Personal Effects NO VALUE TOTAL (Also enter on line 5, Recapitulation) $ 21, 768 . 50 (If more space is needed, insert additional sheets of the same size) Sep, 27 01 02:01p ALLFIRST CIS 3029342955 p.2 allfirst AJI[ItSt Financial Cenret N A. PO Box 900 MilIboro. DE 19966 September 27, 2001 Placey & Wright Attorneys At Law 3631 North Front Street Harrisburg, PA 171l0-1533 Re: Estate of Dorothv M. Crook Social Securi/v: 188-32-4260 Date of Death: AUfrnst 19. 200f Dear Sir or Madam: Per your inQui.')' dated September 17, 200] ple3Se be advised that at the time of death, the above-named decedent had ro1 deposit with this bank the following: Type of Account Relationship Checking W/lnrere.rt Accozml Number 0024712752 Ownership (Names of) Dorothy M. Crook, O\.\mer Opening Date 08/28/64 Balance on Date Qf Death $/7,744.85 Accnted Interest $ .49 TotaJ .--$P1."743.-14-.-.--.--.-.....--... ..-...............-.-. 7i,js l/?/Ii!r d:;es nol illr:/lide anyaccounJs (n which the deceaJed may have been /i.lled 03 Pow" of AtlornlY. CUJlodjan of Uniform 7'roItJ/U3. Represenrarive PlJ)Iee, or Truslee under a Written Agree_m. For jw-,I1f:f accOl<Tltlnfo,marlon. closures and/or reimbursement qf.funtb refer 10 be/ow b,anch: HARRISBURG l'I-fA1N OFFICE 213 MARKET STREET HARRISBURG. PA 17101 717-255-1072 ];~~ 'S"~ Assistant I Cis Services, (302) 934-2909 ~..~."" '* COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF DOROTHY M. CROOK FILE NUMBER 21-01-0825 ITEM NUMBER 1. 2. 3. This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY INClIU THE NAME OF THE TRANSfEREE. THEIR RElAl10IlSHIP TO DECIDEHT AND THE DAlE OF lRANSfER. ATT-'ClI A rol'Y OF THE DEal FOR REAl. ESTATE. %OF DECD'S INTEREST DATE OF DEATH VALUE OF ASSET EXCLUSION ~F APAJCAIllE) TAXABLE VALUE United Olympic Life Insurance Company ING ReliaStar Life Insurance Company Annuity Contract 1A02360050. Beneficiary Meribeth Reed, grandniece Transferred 08/19/01. 108 monthly payments due @ $135.90/mo Value calculated as follows: 135.90 x 12 = 1,630.80 1,630.80 x 6.9867 = 11,393.91 (See policy documents attached) th 100% 11,393.91 11,393.91 Southwestern Life Insurance Company Annuity Policy No. 0006323570. Beneficiary Meribeth Reed, grandniece Transferred 08/19/01. 7,773.74 (See letter attached) 100% 7,773.74 Dorothy M. Crook Revocable Trust Unde Agreement with Allfirst Trust Company of Pennsylvania, NA. Beneficiary Meribeth Reed, grandniece 80%; Zane R. Meixner, nephew, 20%. Transferred 08/19/01. 50,430.49 (See bank letter and Agreement attached) 100% 50,430.49 TOTAl (Also enter on line 7. Recapitulation) $ 6 9 , 5 9 8 . 1 4 (If more space IS needed. Insert additional sheets of the same size) UNITED OLYMPIC LIFE INSURANCE COMPANY 110-110TH AVENUE, N.E. BELLEVUE, WASHINGTON 98004 ANNUITY CONTRACT NUMBER: ANNUITANT: ISSUE AGE: ISSUE DATE: FIRST PAYMENT DATE: OWNER : SINGLE PREMIUM: BENEFICIARY: AS DESIGNATED IN THE APPLICATION UNLESS SUBSEQUENTLY CHANGED. UP-7031-85-UOL I J t~j_::'k..j-,:rl ;j",~ CLrIu r If ~&6~ 1A02360050 DORORTHY M CROOK 86 F NOVEMBER 13, 1990 DECEMBER 13, 1990 THE ANNUITANT $16,271.17 THIS IS A LEGAL CONTRACT BETWEEN THE POLICYOWNER AND THE COMPANY. ******************** * READ YOUR POLICY * * CAREFULLY * ******************** __~,~".J,~L....l-S":I..~."'''.'.'\. ....... .-..''',.... ANNUITANT: DOROTHY M. CROOK TERMS OF ANNUITY: ANNUITY CONTRACT NUMBER: l.A02360050 AGE: 86 F "BEGINNING WITH THE FIRST PAYMENT DUE ON DECEMBER 13, 1990, THE ANNUITY DATE, MONTHLY PAYMENTS OF $135.90 WILL BE MADE ON EACH 13TH DAY DURING THE LIFETIME OF THE ANNUITANT, CEASING WITH THE PAYMENT TO BE MADE ON THE PAYMENT DUE. DATE IMMEDIATELY FOLLOWING DEATH OF THE ANNUITANT. IN THE EVENT OF THE DEATH OF THE ANNUITANT BEFORE 240 PAYMENTS HAVE BEEN MADE, THESE WILL CONTINUE UNTIL THE LAST PAYMENT DUE NOVEMBER 13, 2010." UP-7031-85 Page 3A .08/22/200l 05:05 4255738755 ING,Ii) Relia$tar lif~ Insurance Company ING Minot Sen'ici! Center P.O. Box 5050 MiUQt, North Dakota 5870~ IN PAYMENT OF = 1 A02360050 PAYMENT DU~ DATE: 01/13 PAY EXACiLY: ONE HUNDRED THIRTY~F1VE AND 90/100 F'AY TO 'tHe ORDER OF: MARIBETH M RE~D 19132 ROMAN WAY GAITHERSBURG MD 20886 MERIBETH REED PAGE 02/02 CHECK NO. 32918311 Be JANUARY os, 2002 $135.90 -----------------~---------------------- NONftN~GOTIABLE COpy R1964 B8/22(20dl 05:05 425573875t. MER I BETH REED PAGE 0:/0:i EJ Southwestern Life Il'..8urance Company P.O. Box '7491)05 Dallas, TX. 75374-9005 1 ~800-792-4368 Januar:.r 9, 2002 Meribeth M Reed 19132 Roman 'WaS Gaithet'sburg MD 20886 Re:- POlley NO:""-:OOO632357o--- Dorothy Crook1 deceased Dear Ms. Reed: We wish to express our sincere sympathy to you and your family in your loss. Enclosed is our check in the amount of $7,773.74. Policy number 000632357Q provided an annuity death benefit in the amount of $7,773.74. If you have any questions, please do not hesitate to give our office a call. Our toll ftee number is 1-800-792-4368 ext. 7701. Sincerely, _ ~~~({r Senior Claims Representative ALLFlRST TRUST COMPANY OF PENNSYV ANIA, NA TRUSTEE UNDER AGREEMENT WITH DOROTHY M. CROOK DATE OF DEATH - 8/19/01 PRI~CIP AL: ARK. Money Market Portfolio Accrued interest $ 26.62 3.21 2,470.124 shs ARK. Funds Short-Term Bond Portfolio Accrued interest 24,849.45 60.91 2,565.569 shs ARK. Funds U. S. Government Bond Portfolio Accrued interest 25,450.44 67.17 LESS: Trustee's fee to Date of Death (27.31) $50,430.49 '=:r:G;;- '."!.._~r.;:;;;;:-r'" ~'-. '-i""~ .'.-" ~:~~-,~,~~. ':: .'.~~ \':. '., . ~ . I ~..~'-,,::." I . I ~:,:.. "....~ '...~.-'" .. -. " J ,J'" .. ,- -:..:i,f.- ,.,: !,.!.- - FIRST AMENDME1lI"T TO REV~ABLE LIFETIME TRUST AGREEMENT i ~.: ""'" ~ DOROTHY M. CROOK ("Settlor"), now of Camp Hill, Cumberland Countyt Pennsylvania. hereby amend the Revocable Lifetime Trust Agreement executed October 4, 1991, I which DAUPHIN DEPOSIT BANK AND TRUST COMPANY is the Trustee, in the fullov.ing respect only: , ITEM I: Paragraphs A. B and C of Article Second are hereby deleted and, in lieu tbereo~ the rollov.ing is inserted: 1& A.. Twenty (20%) percent thereofto my nephew, .lANE R. MEIXNER, and his wife, GERTRUDE ~ or the survivor of them, or their issue, per stirpes. B. The remainder thereof to my grandniece, MERIBETH REED, or her issue, per stUpes." ITEM II. In all other respects, I hereby ratifY and confum said Trust Agreement. The foregoing Amendment is hereby accepted. A TIEST: DAUPHIN DEPOSIT BANK AND lRUSTCOMPANY ~~ ~ . Secretary Br. A,~_m~IJ~_ Title Dated: 07-c:;3 - f 7 VICE P~ES1()ENr .. 1~ usr Ot;FfCfR ,':0 0 !PI l.d~a J.smu J.SHU'TTV Qr.gnr.7.L IL YV..J gO; TT 7.0/RO/r.O REVOCABLE LIFETIME TROST AGREEMENT I, DOROTHY M. CROOK (hereinafter referred to as "Settlor"), now of Harrisburg, Dauphin County, Pennsylvania, hereby transfer to DAUPHIN DEPOSIT BANK AND TRUST COMPANY, Harrisburg, Pennsylvania (hereinafter referred to as "Trustee"), a Pennsylvania bank and trust company, the property described in the attached schedule, to be held in Trust as follows: lifetime: FIRST: Dispositive Provisions for my Benefit: During my A. All of the net income Shall be paid to me at least quarterly or shall be paid or accumulated and added to the principal, as I may direct in writing. B. As much of the principal as I may from time to time request in writing shall be paid to me, or as I may otherwise direct. C. If, in the Trustee's opinion, I am at any time unable to act or to apply the paYments to my own best interest and advantage, the Trustee may apply directly for my benefit as much of the income and/or principal as the Trustee may, from time to time, deem appropriate for my welfare, comfort, support or emergency needs and may add to principal as much of the income as the Trustee deems advisable. D. Trustee shall keep true and correct books of account, which books of account shall at all reasonable times be open to the inspection of Settlor or her duly appointed representative. Trustee shall also quarterly render to Settlor a detailed statement showing all receipts and disbursements on account of the trust estate and the manner and form in which the trust estate is invested at the time of the rendition of such statement. SECOND: Disposition After my Death: Upon my death while this Trust continues, Trustee shall pay all of my then outstanding debts including expenses of my last illness, funeral expenses, costs of my gravemarker, if any, all taxes due during my lifetime and in consequence of my death, and fees and expenses incurred in settling my affairs and estate, if any, and shall distribute the balance of the principal and income of this Trust as follows:. A. Thirty (30%) percent thereof to my grandniece, SHERI M. DiSIMONE, or her issue, per stirpes. B. Twenty (20%) percent thereof to my nephew, ZANE R. MEIXNER, and his wife, GERTRUDE MEIXNER, or the survivor of them, or their issue, per stirpes. c. Fifty (50%) percent thereof to my grandniece, MERIBETH REED, or her issue, per stirpes. THIRD: Right to Revoke and Amend: I reserve the right to revoke or amend this Trust, in whole or in part, at any time and from time to time by an instrument in writing, delivered to the Trustee and intending to take effect during my lifetime; except that the duties, powers and liabilities of the Trustee shall be changed without its written consent. The Trustee reserves the right, at any time, upon thirty (30) days advance written notice to me, to resign and deliver the trust estate to me, ~fter deducting therefrom its fees and any expenses then due and payable. FOURTH: Additions to Trust: Subject to the approval of the Trustee, either I or any other entity may add property, real and personal, to the principal of this Trust. FIFTH: Trustee's Powers: In addition to the powers granted by law, my Trustee shall have the following discretionary powers, applicable to principal and income, which shall be exercisable without leave of court and shall continue until distribution is actually made: A. To accept and retain any and all property, holding stock or other securities of the Trustee or of a holding company controlling the Trustee. B. To invest in all forms of property (including, but not by way of limitation, real estate, all types of stocks, bonds, options and participations in common trust funds and money market funds), without being confined to investments prescribed by statute and without being required to diversify. c. To buy investments at a premium or discount. D. To hold property unregistered or in the name of a nominee. E. To give proxies, both ministerial and discretionary. F. To compromise claims. G. To join in any merger, consolidation, reorganization, voting trust plan, or other concerted action of security holders, and to delegate discretionary duties with respect thereto. H. To borrow from itself or from others, and to pledge real estate or personal property as security therefor, to loan cash or securities upon such terms and conditions as Trustee deems appropr ia te . - - 2 - I. To sell at public or private sale for cash or credit or partly for each, to exchange, to improve, or to lease for any period of time, any real or personal property, and to give options for sales, exchanges or leases. J. To allocate any property received or charge incurred to principal or income or partly to each without being obliged to apply the usual rules of trust accounting. K. To distribute in cash or in kind or partly in each. L. To retain any part or all of my business interests held in this Trust as long as the Trustee considers it advisable to do so, and to conduct, alone or with others, any such business in which I am engaged, with all the powers of an owner or with respect thereto, including the power to delegate discretionary duties to others and to pay adequate compensation to any such persons, to invest other property in such business and to incorporate it or change its form. SIXTH: Compensation: The Trustee shall be compensated in accordance with its standard schedule of charges in effect from time to time during the period of its services, and this compensation shall be paid from principal or income or partly from each in the sole discretion of the Trustee. SEVENTH: Non-Assignment: No part of the income or principal of the property held under this Trust shall be subject to attachment, levy or seizure by any creditor, spouse, assignee or trustee or receiver in bankruptcy prior to actual receipt thereof. The Trustee shall pay over the net income and the principal to the persons herein designated, as their interests may appear, without regard to any attempted anticipation (except as specifically provided in this agreement), pledging or assignment under the Trust, and without regard to any claim hereto or attempted levy, attachment, seizure or other process against me. EIGHTH: Law Governinq Trust: This Trust is created and accepted in the Commonwealth of Pennsylvania and shall in all respects be governed by its laws and shall have its situs at Dauphin County, Pennsylvania. v~ -/?/- t!~ Dorothy M. Crook ,,----- APPROVE~~ {/oa.-~ 7 DAUPHIN DEPOSIT BANK AND TRUST COMPANY By: ~~~~ Vi P ..', '1" '1""'" .- "es'"",~"l'~" <I ':"''': '" ,: ')'".~ .\.-';; . < __ ...._.. \._:._, l. ~ ,. -.._ - 3 - COMMONWEALTH OF PENNSYLVANIA: : SSe COUNTY OF DAUPHIN . . On this, the 4~ day of October, 1991, before me, the undersigned officer, personally appeared Dorothy M. Crook known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that she executed the same for the purposes therein contained. IN WITNESS WHEREOF, I have hereunto set my hand and notarial seal. ~./J. ~~ ota y Pub ic My Commission Expires: r' HT,'~'!"1 S~,~.l 1 \ HOt; ,{- " -l!';!;C I ~ Hili,"'V I , ' 'jrr'-' 1 MyCOTli;i'~:>:~, '..., '., .1.':1J L-- $20,000.00 $ 2,000.00 $10,000.00 $10,000.00 $10,000.00 SCHEDULE "An Cash - Transfer from checking account Dauphin Deposit Bank Certificate of Deposit, 7.85%, due 10/27/90 - #43573, now 7.65% due 10/27/91 Dauphin Deposit Bank Certificate of Deposit, 6.80%, due 11/6/87 - #949013, now 7.55% due 5/6/92 Dauphin Deposit Bank Certificate of Deposit, 7.80%, due 7/30/87 - #945514, now 7.90% due 1/30/92 Harris Savings Association Certificate of Deposit, 8.750%, due 5/6/87 - #79981, now 8.21% due 11/6/91 Policy #86D0057 - Life Assurance Company of PA Policy #87D0007 - Life Assurance Company of PA Policy #21961 United Security Assurance Company of PA (Nursing Home and Custodial Care) Certificate of Application - Integon Life Assurance Corp. Policy #IA 02360050 United Olympic Life Insurance Company Pre-arranged Funeral Documents with W. Orville Kimmel Funeral Home, Inc. REV-1511 EX+ (12-99>. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF DOROTHY M. CROOK FILE NUMBER 21-01-0825 ITEM NUMBER A. Debts ot decedent must be reported on Schedule I. DESCRIPTION 1. FUNERAL EXPENSES: W. Orville Kimmel Funeral Home - Saturday grave openin B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions 2. Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) Street Address City State _ Zip Year(s) Commission Paid: AtlomeyFees Placey & Wright 3. Family Exemption: (II decedenfs address is not the same as claimant's, attach explanation) Claimant 4. Street Address City State _ Zip Relationship of Claimant to Decedent 5. Accountanfs Fees ProM~Fees Cumberland County Register of Wills 6. Tax Return Preparer's Fees 7. 8. 9. Patriot-News Company - estate advertising Placey & Wright - reimb. of costs advanced Cumberland Law Journal - estate advertising - Cumberland Co. Reg. of Wills - short certs. - Reserve for future costs, taxes and expenses $75.00 6.00 TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) AMOUNT 300.00 n/a 6,500.00 n/a 83.00 91.38 81.00 1,500.00 8,555.38 RfV.1S12 EX . (1-97] SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS COMMONWEALTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FilE NUMBER 21-01-0825 DOROTHY M. CROOK Include un reimbursed medical expenses. ITEM NUMBER DESCRIPTION 1. West Shore EMS - debt of decedent 2. Verizon - debt of decedent 3. SouthCentral EMS, Inc. 4. Metropolitan Medical, Inc. - debt of decedent 5. Homeland Center - debt of decedent 6. Community Lifeteam, Inc. - debt of decedent 7. PA Public School Retirement System - reimb. direct depc sit 8. The Woods Assisted Living - debt of decedent AMOUNT 37.20 56.13 75.00 48.00 161.42 339.00 765.41 240.00 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed. insert additional sheets of the same size) - 1,722.16 REV-1513 EX+ (9-00) *' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF DOROTHY M. CROOK ALE NUMBER 21-01-0825 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not Ust Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. Zane R. and Gertrude Meixner Nephew 20% Residue 103 Tower View Drive Butler, PA 16002 2 Meribeth Reed 19132 Romans Way Gaithersburg, MD 20886 Grandniece 80% Residue ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET n NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART n - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ - 0- (If more space is needed, insert additional sheets of the same size) LAST WILL AND TESTAMENT OF DOROTHY M. CROOK I, DOROTHY M. CROOK, now of Camp Hill, Cumberland County, Pennsylvania, declare this to be my Last Will and Testament and hereby revoke all prior Wills and Codicils made by me. ITEM I. I direct that all of my just debts and funeral expenses, including the cost of my gravemarker, if any, shall be paid for from my residumy estate as soon as practical after my decease as an administrative expense of my estate. ITEM II. I give and devise all of my estate of every nature and wherever situate as follows: A. To my nephew, ZANE R. MEIXNER, and his wife, GERTRUDE MEIXNER, or the survivor of them or their issue, per stirpes, I give my grandparents' Chinese chair and twenty (20%) percent of the residue of my estate. I direct that the cost of shipping the chair to the beneficiaries shall be an administrative expense of and be paid by my estate. B. The remainder of my estate I give to my grandniece, MERIBETH REED, or her issue, per stirpes. ITEM m. If any income or principal shall be payable to any person who shall be under the age of twenty-one (21) or who shall be incapacitated for any reason, my personal representative, as trustee, shall hold such income and principal for such beneficiary until the age of twenty-one (21) J) ~ ~ -{J~~ Dorothy M. Croo .. . or during incapacity and shall be entitled to apply such income and principal to the health, maintenance, support and education of such person without the appointment of any guardian or committee or any authority of court, and shall be entitled to make direct application hereunder or to make application by payment thereof to the parent or other person in charge of such person, or to his or her guardian or to a custodian under the Uniform Transfers to Minors Act. Any remaining income and principal to which such person shall be entitled shall be paid and distributed to such person upon attaining the age of twenty-one (21) or upon the termination of incapacity. ITEM IV. I appoint DAUPHIN DEPOSIT BANK AND TRUST COMPANY, Harrisburg, Pennsylvania, Executor of this my Last Will and Testament. No bond shall be required by my personal representative in any jurisdiction. ITEM V. In addition to the powers given by law to my personal representative(s) and trustee( s) [hereinafter fiduciaries] in the administration of my estate and of any trust(s) created herein, they shall have the following discretionary powers applicable to all real and personal property held by them, including property held for minors, effective without court order until actual distribution. A. To retain any property owned by me at my death and to invest any funds held by them in any stocks, bonds, notes or other securities or property, real or personal, including common trust funds, mutual funds and money market deposit accounts operated or offered by my corporate trustee, if any, or any affiliate of it. B. To sell or otherwise dispose of any property, real or personal, at any time forming a part of my estate or the trust estate, for cash or upon credit, in such manner and on such terms as ~~4~'~ Dorothy M. Crook 2 they see fit, and no one dealing with the fiduciaries shall be bound to see to the application of any monies paid. c. To manage, operate, repair, improve, mortgage or lease for any term [even ifbeyond the duration of the tnlSt(s)] any real estate at any time held or owned by them as fiduciaries. D. To hold investments in the name of a nominee and exercise and dispose ofwanants. E. To engage in litigation and compromise, arbitrate or abandon claims and property. F. To conduct any business in which I am engaged or in which I have an interest at the time of my death for such period as the fiduciaries deem advisable, with the power to boITOW money and to pledge the assets of the business and to do all other acts which I, in my lifetime, could have done, or to delegate such powers to a partner, manager or employee without liability for any loss occurring therein. G. To allocate items of receipt or disbursement between principal and income as the fiduciaries deem equitable regardless of the character given such items by law; to distribute in cash or kind or partly in each at valuations fixed by the fiduciaries. H. To boITOW money, including the right to boITOW from any corporate trustee, if any, and to mortgage or pledge as security or to hold its own stock if a corporate trustee. 1. To join in any merger, reorganization, voting trust plan or other concerted action of security holders, and to delegate discretionary duties with respect thereto. J. Should the principal of any trust herein provided for be or become too small in trustee's opinion so as to make establishment or continuance of the trust inadvisable, my trustee(s) may make immediate distribution of the then remaining principal and any accumulated or undistributed income dP~ & - (!7~ Dorothy M. Crook -- 3 .. outright to the person or persons and in the proportion they are then entitled to income. Upon such tennination, the rights of all beneficiary(ies) who might otherwise have an interest as succeeding income beneficiary(ies) or in remainder shall cease. K. In general, to exercise all powers in the management of the assets of my estate or the trust estate which any individual could exercise in the management of similar property owned in his own right, upon such terms and conditions as the fiduciaries may deem best, and to execute and deliver all instruments and to do all acts which the fiduciaries may deem necessary or proper to carry out the purposes of this will or any trust(s) created herein. L. To apply income or principal to which any beneficiary is entitled, directly for his or her comfort, maintenance and support, should the fiduciaries deem such beneficiary incapable of receiving the same by reason of age, illness, infinnity or incapacity, or to pay the same to such person or persons as the fiduciaries select to disburse it, whose receipt shall be a complete acquittance therefore without the intervention of any guardian. M. To assume continuance of the status of any beneficiary with reference to death, marriage, divorce, illness, incapacity or other change in the absence of information deemed reliable without liability for disbursements made on such assumptions. N. All principal and income shall, until actual distribution to any beneficiary, be free of the debts, contracts, alienations and anticipations of any beneficiary, and the same may not be liable for any levy, attachment, execution or sequestration while in the hands of any beneficiary, and the same may not be liable for any levy, attachment, execution or sequestration while in the hands of any fiduciaries. jjJ~~~ ~- Dorothy M. Crook 4 IN WTINESS WHEREOF, I have hereunto set my hand and seal this ..?D1>)day of q u r\...L; , 1997. u~~\"~ Dorothy M. Crook The preceding instrument, consisting of this and four other typewritten pages, identified by the signature of the testatrix, as on the day and date thereof signed, published and declared by Dorothy M. Crook, the testatrix therein named, as and for her last Will, in the presence of us, who, at her request, in her presence and in the presence of each other, subscribed our names as witnesses hereto. It?!fr(; 7Jftt/t1Y#~<-ff,4 171/~ :;260 N. S,...-J J1 ;f7.JJ7HMJOAr' v: l '7ttt( 5 ~ . ,. ACKNOWLEDGMENT COMMONWEALTH OF PENNSYLVANIA: : SS. COUNTY OF DAUPHIN I, DOROTHY M. CROOK, testatrix whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my last Will, that I signed it willingly, and that I signed it as my free and voluntary act for the purposes therein expressed. ~~~ t!~ Dorothy M. Crook Sworn or affinne~~ acknowledged before me, by Dorothy M. Crook, testatrix, this 10-h1 day of ~ I\.L.. . 1997. -1-1,.11 , . ~ _ ,.) UJ( I I 'I Notary ~blic My Commission E ires: AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA: : SS. NOT AR1Al SEAL HOLLY S. KIRK, Notary Public Harrisburg, Dauphin County My Commissi~n Expires Feb. 15, 1999 COUNTY OF DAUPHIN We, CCDr Q n d aId _ fa , the witnesses whose name are signe to the attached or foregoing instrument, being duly q ified according to law, do depose and say that we were present and saw testatrix sign and execute the instrument as her last Will; that she signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the testatrix signed the Will as witnesses; and that to the best of our knowledge the testatrix was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. 1997. Sworn to and subscribed before me this 20m day of C) u N