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Home My WebLink About01-0828 JrJtestacy PETITION FOR GRANT OF LETTERS OF ADMINISTRATION ADMINISTRA nON tea.. 02 \ - 0\ - o;;}.,€> .......... No........................................... Intestacy Estate of . Michael G. Gossert Also known as . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . To: . . . . . . . . . . . . . . . . . . . .. . ... . . . . .. ................. Social Security No. . .~62-:-~~.-.58~O. . . . . . . . . . . .. . . . .. Register of Wills for the Cumberland County of B~in the Commonwealth of Pennsylvania . . . . . . . . .. . . . . . '" ........ . . . . . . .. . . . . . . Deceased. The petition of the undersigned respectfully represents that: Your petitioner~ who is~~ 18 years of age or older, appl i~~ . . . . . . . . . . . . for letters of administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . on the estate of the above decedent. (db n pedenle ille. durante cbslenlla. dura"te mlnontate) (Borough of Shippensburg) . Decedent was domiciled at death in Cumberland County, Pennsylvania, with hl,~ . . . last family or principal residence at. . . .1 ~ . ~ou.t.h. . Q~~~n. .S.t.r:~~ ~? . .S.~~I!p~~?~.u.~g,. . ~~. . .l? ~~ ~ . . . . . . . . . . . . . . . . . . .'.. . . . . 28 200 1 -:JIS~ stre~l nt.:mber and mUnlclpall;YI Decedent, then. . . . -?? years of age, died. . . ~.u.g.u.s.t. . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . , :ll~ . . . . . . . at. .C;Qq.l!lP~.r.s.~q~g )fppp,i,t;q.-l... C.h.a,1I).QE;!:r:3l>~.r.g,. 1;'A... .1.7..2Ql. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . decedent at death owned property with estimated values as follows: (if domiciled in Pa.) All personal property (if not domiciled in Pa.) (if not domiciled in Pa.) Personal property in Pennsylvania Personal property in County ............ ... .... ............... . ....... " ........ ............................................... Petitioner. . . after a proper search ha E? . . ascertained that decedent left no will and was survived by the following spouse (if any) and heirs: Name Relationship Sister Residence ~?~~~.~:. ~~~&~~~~.. ................ ............. ........ 918 Monroe Street, Oberlin, PA 17113 ................... .................. . .................................... ..........0.0...0... . .... 0 0....................00.0....... . 0.0..00......0.0.000.0....0....0..0. .. 0.0..0.0.0.0... 0... .0. 0.0.0......0........000.........00 . o. 0............................ 0.... .......... 0.0... 0.... 0...........0. 0......... 0............ ............... 0.... 0............. '" . 0....... o. 0......... ..... 0.....0. o. 0.0........ o. 0 0... 0... 0.0..... 0..0...........0.0.0.....0.... 0...0.00.. 0.. o. o. 0.0. . 0.. 0.........0...... 0............... THEREFORE, petitioner(K) respecfully request(s) the grant of letters of administration in the appropriate form to the undersigned. ....... 0...................................... Susan N. Shughart '918 . Monroe 'Street. . . . . . . . . . . . . . . . . . . . . . . . . . . .qqHH)1.,.l~. . PP.3. . . . . . . . . . . . . . . . . . . . . . . . . . .......................0...0.......0......... . \~ - <0 - q OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA COUNTY OF ~CUMBERLAND } ss 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 said decedent petitioner(s) will well and truly administer the estate to law. Swom to 0' a!li,med and ,ub- --_....._.~~k~~.---_._......._.. scribed before me this . 9T~ day of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ~:~:~..~~~ I t For the Register . .. . .., .................... ......... .., ................ ....... ., ., ... ......................................... .. .... ., ., .. ........................................... No. .~1 .~.OJ. ~ 828 Estate of. . ~.i.C:~~E7~. <;;~. ~?s.s.e.r.~ . . . . . . . . . . . . . . . . . . . , Deceased GRANT OF LETTERS OF ADMINISTRATION ANDNOW ..... .~~prE.M~~~. 7............ ~.~99~., in considerationofthe petition on the reverse side hereof, satisfactory proof having been presented before me. IT IS DECREED that ....... .S.u.~8:1?-. ~... ?~~g~~~~. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . is~ entitled to Letters of Administration, and in accord with such finding, Letters of Administration .................................................... ............................................... are hereby granted to . . ~':l::>~?-. .~.. . ~1,1~~~.a.r:~ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .................................................................................................. . in the estate of . . . . ~~c:~~~~. .G... .~<?!;'::>~~.t. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . and bond, if required, fixed in the sum of $. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , is approved and filed. Documents Attached: Bond $ . . . . . . . . . . . . . . . . . . . . . . . . 0 Renunciation{s} ~ /P (() . Le..-\:- JJ ~dm. ~O.~..... .L....~.~........ . ....... . ~h.C.e...'\-l.(b) \5.~ Register of Wills MARY C LEI IS :S~1? 5.~ David C. Cleaver 07283 \06.\ ~ l t) D. ~. . . . . . . . . . . . . . ., . . ATTORNEY '(S~~"Ct."i.D"N~:)' . . . . . . . . . . . . . . . . . . 1035 Wayne Avenue Chambersburg. PA 17201 ................................................. ................. Address ............ -...................................................... 717-264-1110 Phone H105.805 REV 9/86 This is to certifY that the information here given is correctly copied from an original certificate of death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. p 7645729 Fee for this certificate, $2.00 No. ~l J'~ 2c>oL Date ' '!\I' 2117 COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH NAME OF O!CEDENT (F".. MidCIe. L_ L Michael G. Gossert AOE(L.- ~ UHOEA 1 YEAR -~:' Do,. 52 Vro. COUNTY CI 0EArH SEx S"Da'1"JJU:___" SOC....L SEct1RlTY NUMBER ORE 0I.8IR1'H lMoriltl.Oey,'''. -tav_ SlMeorFor-onCoul'lri'yt .. Male, .. 162 - 42 PLACI:"OIF oe.rH~~ oHy or-. ...,,,.rl.C!lOnfl on or. .. .Cliamerstmg, PA '- 0 (Ifnollf\lflUlDn.~*Nland~ =""0 Franklin DECE NT'S USUAL (oI-=:~~~"" .. ,I. White SUFMWIG SPOUSE 1"......gro/I8lnK11lntWMl _. Ie. -.-.....-.LoIl) 'I. Robert F. Gossert -._cr Susan N. Shu hart lolE11OOOCI _0 ~~ ___0 0Il0r_ Shippensburg - 21783 17257 ___CAUIIfF... '-elI' cancMion ....-.o..~--... 1==:-_. :oneetMd.... I I MllTI: Qtw~CCIftIIIIIIaMCIOtIII'lbuItnglOdMth.but ... ........Ift_ ~.......... irt AUn' I. """-..- . . .... ................ --.I_~ . -_....... {c, ", ...,....,... r..ana"~LAIT d. .... AN 0U1I:lPSV """"""",,07 ....0 - ...K- It. MANNER OF DEAI'H -~ o il#n OF IHJUA'Y .o.v.__, TIlliE OF INJURY NJOAV /IS 'M)AI(? DEBCAt8e HOININJURY c:x:ctJRAED - - "-- o o ~ o PUllll!<:I........ -....- - 'tJ! .... 0 -)it ----... On......... oI.........Jon .ndIor ...........IIon. In "'Y opinion. _. 00C1In'ed lit the lime. dIlIe. and phlce,..... to the UUM(atlnd ..........................................................................' ...... .................;;............... '1e. AEGIST'AAA'S SIOHArUflIE AND NUMBER , 11'/ w(v ~ o Could... lie dIWmIned - - """'-~....- .c:BI'fWYWOIIIffftICIAM~~ca.eoldlNlh~.....~.hMpr~dealhaNJ~.......23) 1b..........,~.....................h~.J.......,.,.,_............................ ........... .............. ~ANOCBfrIII'WrIQ~~lMbaltl~dMlhltlclcertlfylnig.lD__afONlt\l To......... "".......... ......~at...tMte, dOl. .........,.. ...........uUee(.......CNftMr................................ ... :M. One Sided, One Page 8 1/2" X 11" Plain White Paper Document COMMONWEALTH OF PENNSYLVANIA COURT OF COMMON PLEAS o FCUMBERLAND COUNTY ORPHANS' COURT DIVISION NOTICE OF CLAIM In Re: The Estate of: MICHAEL GOSSERT Deceased Court File No: 2001-00828 TO: THE CLERK OF THE ORPHANS' COURT DIVISION Notice of claim by creditor, Pursuant to Section 3532(b)(2) of the Probate, Estates, and Fiduciaries Code, 20 PA.C.S.A. 93532(b)(2). 1) Claimant's name: FIRST USA 2) Claimant's address: c/o NCO ATTORNEY NETWORK SERVICES CHEVY CHASE P A VILLION 5335 WISCONSIN A VENUE, NW SUITE 360 WASHINGTON, DC 20015 3) Creditor listed below is the owner and holder of a claim in the amount of $905.88 4) 5) 6) 7) The facts upon which this claim is based is a credit agreement between Creditor and Decedent, identified as account number which is evidenced by the attached affidavit of account stated. Decedent's address: POBOX 560, SHIPPENSBURG, P A 17257-0560 Date of Death: UNKNOWN That the claim arose prior to the death of the decedent on or about 8) That the claim is secured by On behalf of the claimant, I do solemnly declare and affirm nder the penalties of perjury that they Information and representa 'ons made h n are true and correct to the best of my knowledge, information an bel' . Dated: OCTOBER 11, 2001 W/6,A ent Clai ant Written notice of claim was given to Personal Representative and/or hislher counsel as stated below: SUSANN. SHUGHART Name 918 MONROE STREET Address OBEELIN, PA 17113 City/State/Zip OCTOBER 11, 2001 Date notice mailed ~c"'..-t' C d-t S - I 1 Icorp re 1 erVICeS, nc. Citicorp Credit Services, Inc. A Subsidiary of Citicorp Kansas City Regional Center 7920 N. W. I 10th St Kansas City MO 64153 September 28, 2001 CUMBERLAND COUNTY COURTHOUSE 1 COURT HOUSE SQ., RM 102 CARLISLE,PA 17013 RE: The Estate of MICHAEL G GOSSERT File Number: 21-01-828 Dear Sir/Madam, Please find enclosed our claim against the above mentioned estate. Please return a FILED stamped copy in the enclosed envelope. Thank you for your attention to this matter. Very Truly Yours, SHAWN HARMER Manager, of Citicorp Credit Services, Inc. under limited power of attorney for Universal Bank, N.A. t ~ ~ ~ ~~ -- ~ u c . C- IA :::3 ..... Nj ~e~tr\ - C' .... ........ ~:;;V)~ J:U-50 :!::o~~ 1 ~- ~ U.. 10 t:> .::: :o~u e- 'iij z '" o.co~ ~~~~ U~i'-::':: @ (€ u .. IN THE COURT OF COMMON PLEAS OF CUMBERLAND County, PENNSYL VANIA ORPHANS' COURT DIVISION File No. 21-01-828 Estate of MICHAEL G GOSSERT SSN- 162-42-5880, Deceased NOTICE OF CLAIM by Universal Bank, NA., filed pursuant to Section 3532 (b) (2) of the Probate, Estates, and Fiduciaries Code, 20 Pa.C.S.A. &3532 (b) (2). TO THE CLERK OF THE ORPHANS' COURT DIVISION: Enter the claim of Universal Bank, NA., in the amount of $ 389.43, against the above- captioned estate. The Decedent, who resided at PO BOX 560, SHIPPENSBURG,P A 17257 CUMBERLAND County, Pennsylvania, died on 08/28/2000. Written notice of said claim was given to: SUSAN SHUGHART 918 MONROE ST " . I OVERLIN,PA 17113 , DAVID C CLEAVER 1035 WAYNE AVE CHAMBERBVRG,PA 17201 on September 28, 2001. Universal Bank, NA Account _~~4~1~ SHA R, manager for Citicorp Credit Services, under limited power of attorney for Universal Bank, NA No. 5398570040115678 Claimant's Counsel: n/a P.O. Box 20432 Address Kansas City, Mo. 64195 (C!,h~~~u::tk- '---J ~HRIS ClINESMITH Notary P ic - Notary Seal State f Missouri Platte County My Appt. Expires November 6, 2004 . PROOF OF CLAIM ORPHANS COURT DIVISION COURT OF COMMON PLEAS CUMBERLAND COUNTY O.c. No 21-01-828 ESTATE OF: MICHAEL G GaSSERT DECEASED Social Security Number: 162-42-5880 Date of Death: 08/28/2000 Name, Address & Phone No. of Person Filing Claim: Shawn Harmer Agent for Claimant Citicorp Credit Services PO Box 20432 Kansas City, Mo. 64195 1 800215-6061 Your A18!r Universal Statement August 15 - September 13. 2000 -- 8([ . Page 1 of 2 MICHAEL G GOSSERT Account 5398 5700 4011 5678 Calling Card 8701783518+ PIN No Annual Fee How to Reach Us Account Online: WWW.universalcard.com Account OnCall: 1 800636-8330 (For Automated Service Only) Customer Service: 1 800423-4343 or write Universal Card Services Corp.. PO Box 44167 Jacksonville. FL 32231-4167 L Quick Reference Minimum Payment Due..............................................S20.oo Due Date'" .................................................... October 9, 2000 'Payment must be received by 1:00 pm locar time on the payment due date. - Credit Line.............................................................. $4,000 .00 Available Credit...................................................... $3.254.00 Cash Advance Limit ...............................................$2.500.00 L Account Summary Previous Balance Payments and Ad;ustments MasterCardClO Activity Total AT&T Services New Balance Note: Detailed activity starts on page 2. $783.72 -50.0Q 11.50 0.00 $745.22 4 "l4f;. 'L?. -ll.SOI=C. ~ ll"3>-=b,72 ~R BAt- Payment Record Amount Paid: Date Paid: Check Number: Please follow payment Instructions In the Hlmportant Instructions for Making PaymentsH section of the original statement. Account Number Pa ment Due New Balance Minimum Pa ment Enter Amount Enclosed 5398 5700 4011 5678 ~ 10/09/00 $20.00 $ Make changes to address snd phone number below: Address Apt./Suite City State Zip Home phone ) Business phone ) o E7 559857 08 00 C MICHAEL G GaSSERT po BOX 560 SHIPPENSBURG PA 17257-0560 Make check payable to: Universal Card PO BOX 8208 SOUTH HACKENSACK NJ 07606-8208 ", """"," "" """ """"""" """"" """"""" 53985700401156780000020000000745224 t _. .............. "i... III II' : f"'-.. f- a o G. ~ -5 ,~ Or) ~~ ...", ':: ~ ~ ~ ;0.',::: ... '0 t;.- ~ ~U ~~ ,':::t '& '-' ~ ~ ~- :::: C- O .S! ~ (i e-~ <: ~ Q.-::, C '" ,"!:/ ,:;! <"l:: :<::t -J ?- ~ U"'l:; " ~ <"1, ~ ---- '~ \ -,- ~''J '.. , " ~\ .... STATE OF PENNSYLVANIA IN RE:ESTATE OF MICHAEL G. GOSSERT IN THE REGISTER OF WILLS COURT: CUMBERLAND COUNTY ESTATE NO. 2001-00828 STA TEMENT OF CLAIM 1. MBNA America hereby presents for filing against the above estate this statement of claim in the amount of $ 479.82. 2. The basis for the claim is MBNA account number 5490994306035528 which was opened on 7-9-99. 3. The tax identification number of the claimant is 510331454. 4. The name and address of the claimant is MBNA America. 1000 Samoset Drive. Wilmin2ton. DE 19884. 5. This claim IS NOT contingent. 6. This claim IS NOT secured. 7. The last payment made on the account was $ 30.00 on 7-28-01. Under penalties of perjury, I declare that I have read the foregoing, and the facts alleged are true, to the best of my knowledge and j~ I ^ J Executed this day of ~~ ,2001 State Of Delaware, County of Kent IN WITNESS WHEREOF, I have set my hand and notarial seal this ~3 day of O~A . , 2001 DAWN M PEUGH NOTARY PUBLIC STATE OF DELAWARE ~y COMMISSION EXPIRES ON 12.112/02 J:JkK71/lJfl~ Notary Publ My Commission ExpiresJ d-.), d" / O~ I / ' 4 X165-1 CUSTOMER INFORMATION SYSTEM 10/18/01 * 5490994306035528 * 07:21:30 MICHAEL G*GOSSERT CURBAL: 519.63 CYCLE: 05 N 0000000000000000 CR LIN: 11300.00 STATUS: 5 CHANGED: 09/07/01 ***************************** AUGUST STATEMENT ***************************** POST -------REFERENCE------- TRAN --------DESCRIPTION------_ BC ---AMOUNT--- PAYMENTS AND CREDITS 0728 20952972928 PAYMENT - THANK YOU 30.00CR ***************************** AUGUST STATEMENT ***************************** PREV BAL - $504.67 PAY + $30.00 SALE + $0.00 CASH + $0.00 F/C $5.15 = NEW BAL $479.82 PF10=PAGE FORWARD PF11=TRANSACTION SUMMARY 4-@ 1 MBNAIS PF06=SEPTEMBER STMT PF15=JULY STMT 192.168.14.10 PA1=BEGIN AGAIN 1 PA2=SYSTEM MENU AAS6 WDA42J45 2/31 -- IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ESTATE OF MICHAEL G GOSSERT , Deceased No. 21-01-828 of 2001 To the Clerk of the Orphans' Court: Enter the claim of CAPITAL ONE Acct. 5291491872091358 In the amount of $1,081.86 , against the above entitled estate. The decedent, who resided at PO BOX 560 SHIPPENSBURG PA 17257 died on 08/28/2001 . Written notice of said claim was given to SUSAN M SHUGHART (Personal Representative or counsel) 918 MONROE ST, OBERLIN, PA 17113 ,if known to claimant, at on November 20,2001 (Date) ~_xi, ..;U ~--'-"'-- (C a" ant) Address: 5330 East Main Street, Suite 200 Columbus, Ohio 43213 Claimant's Counsel Address pc; =<<l ::1 ;.. 0", m <:; [:;.. -", c~~ :;.' es <: ~ d ..... l!~ (00 ~~~a ,", ("f ~; Ct 8., CJ ::,'1~ ::E (ir =.: (t" l>>o -. :!:'l ..... U1 ....., () r- )> )> "U )> s:: m ~ I 0 )> C/) 0 0 Z ~ Z ;:0 -i 0 fI:I m CJ5 -i C/) m 0 ....... C/) Z 0 ;:0 ~ )> "U Q) ." ....... 01 s:: I "0 CO s:: "0 """ W m )> """ W () z ~r --- 0 () I C/) C" """ m )> )> () ....... CD ~ s:: "U (') m 0 ':-:"' )> ~ r- C r- C) Z w Z )> ;:0 """ r- -i 0 w C/) 0 s: C) -i CO ~-i 0 Z )> Z C/) 0 "U C/) m C/) "U -i m I\.) m ;:0 ....... r- I () I\.) -i 0 0 ....... )> .0 0 I l:D m CO I\.) r- () () CO m 0 m r- )> C C/) s:: m l:D 0 C C/) 0 I ~ w I\.) ....... w on :o$' ,.. _. d =<1.' :;~ - (1)(') 0" " 1l'2 0 (!) (') ~ vra ..., " 05' in <tl ::l '~. O. Q. ~ Q, (~) () ~F'. . ':.":~ 0 ,.....-., ;;a ?6 . \. " =: (l) () - rifo :'Oc (iJ )>:::;. - ....., t k ~ !II ~ ';. lll"'_~~ ~ \to v._~ '--;~~----'f'Lu r :'1\1.'.11\ f\ ~~ \ ~ i ili ~ ,g\ !\ i I u. I II; 0 ,u~i ~~~, 11~--cJ.~_\ )~~ .... -,... c< ,_ I. r.'i!~ .; ~J>f~;"".~ <r_j '.~ ''''-' I \1..' -'.o;.--~','~l:= ~~ ......* II ,...., ~_,. >. .,' --t, ~ "';-~:_ -', _i: -\: C r;~ ,:--;:---.'-." I.:~~' - '. .. "-. I i\::,/ '. j -' ___, \ \ .".j', -, - I".~'" ~ _:._' \.i.:~ ~ C~, ,-C\ .'''' /. ; :\;";)0 I:) ~ ........;''''''''--......._ .- (.) .5~Ul en C'\I g> 8~:o '~ '::i = c") Q)(J)dlN (J)-_C") CQ)C'O"<:I' o ~ C 0 ~...... 0._ m (J) 'en .r:. EcUlO '- ,- ~ Ul o C'O 0 ::i 'E~'-.o -wO-E 2 0 .~ .2 ~"-C'Oo Ulc")""U WLO.... ~ :J o N o 0 ~ ; ~g ~~:~ >--<( l-3::J ZU.O(Y) :JO(/)..- OO::wR OW(/)..- Ol-:J<( Z(/)Oo... <(<.9IW -lWI--l O::O::O::(/) W..:J:J COz 0 0:: ~I-O<( :J 1-<( 0 o ..- ('l o d fl t9 ~ I ~ .. o l"" .. ~ (~, --6 ~ WELTMAN, WEINBERG & REIS Co., L.P.A. ATIORNEYSATLAW Ree'G~~~1jffi'1e,~fiite 200 rClft#~ qwo \~4~p-l099 1'"lliC;j" -2'16.685.111'0'015 www.weItman.com COLUMBUS 614.228.7272 CINCINNATI 513.723.2200 "01 01 C 1 2 All :51 PITTSBURGH 412.434.7955 Clerk-\ Cllmberid. DETROIT 248.362.6100 December 5, 2001 Register Of Wills One Courthouse Square Carlisle, PA 17013 Re: Estate of Michael G. Gossert Case No. 2101-828 Our Client: Bank of America N .A. Account Nos. 5393649201881800 & 4336009010088183 Balances Due: $ 2,173.70 & $450.66 together with interest at the rate of 10.00% per annum from December 6th, 2001 Our File Nos. 02341153 & 02341105 Dear Clerk of Courts: This law firm represents Bank of America N.A. in connection with its claim which we wish to file on our client's behalf into the estate of Michael G. Gossert, deceased. Enclosed is our check in the amount of$5.00 which we understand is the filing fee for this claim. Our client's claim is based upon its account numbers 5393649201881800 & 4336009010088183 in the amounts of$ 2,173.70 . & $450.66 plus interest which continues to accrue. Included with this letter is the claim form which we wish to present to this court and which we are forwarding to the attorney and/or fiduciary of this estate. It would be appreciated if all correspondence and disbursements with respect to this matter be forwarded to our office and to the attention of the undersigned. Additionally, it would be appreciated if any notices of any hearings also be forwarded to the undersigned. Thank you for your cooperation in this matter. . erel~,~~ raci L. so~ \ Legal Assistant (216) 685-1022 TLGjsa Enclosures cc: Susan N. Sugart, Fiduciary David Cleaver, Esquire "" WELTMAN, WEINBERG & REIS Co., L.P.A. AITORNEYSATLAW 323 W. Lakeside Avenue, Suite 200 Cleveland, Ohio 44113-1099 216.685.1000 www.weltman.com COLUMBUS 614.228.7272 CINCINNATI 513.723.2200 PITTSBURGH 412.434.7955 DETROIT . 248.362.6100 December 5, 2001 CERTIFIED MAIL Susan N. Sugart, Fiduciary 918 Monroe Street Oberlin, PA 17113 Re: Estate of Michael G. Gossert Case No. 2101-828 Our Client: Bank of America N.A. Account Nos. 5393649201881800 & 4336009010088183 Balances Due: $ 2,173.70 & $450.66 together with interest at the rate of 10.00% per annum from December 6th, 2001 Our File Nos. 02341153 & 02341105 Dear Ms. Sugart: This law fIrm represents Bank of America N.A. with respect to the claim which we wish to fIle in the estate of Michael G. Gossert. It is our understanding that you are the Fiduciary of the estate. We are asking that you please accept our client's claim which is based upon its account numbers 5393649201881800 & 4336009010088183 in the amounts of$ 2,173.70 & $450.66 plus interest. Please direct all correspondence and disbursements with respect to this estate directly to our offIce. It would also be appreciated if you contact us to advise us when you anticipate making disbursements in this matter so that we may mark our fIle for follow-up at that time. Thanking you in advance for your cooperation in this matter. This law fIrm is attempting to collect these debts for our client and any information obtained will be used for that purpose. Lastly, do not hesitate to contact us to further discuss this matter. "cer;l~ ~s(1s~O Legal Assistant (216) 685-1022 TLGjsa cc: Susan N. Sugart, Fiduciary- regular mail David Cleaver, Esquire WWR#02341105 & 02341153 FORM 93-0.C. DIVISION IN THE COURT OF COMMON PLEAS of CUMBERLAND COUNTY, PENNSYL VANIA ORPHANS' COURT DIVISION IN RE: ESTATE OF No.2101-828 of Michael G. Gossert Deceased Goods and services purchased on Mastercard & Visa Bank of America N.A. Account No. 5393649201881800 & 4336009010088183 CLAIM To the Clerk of Orphans' Court Division: Index and make proper entry in your official records of the claim of Bank of America N.A. c/o Weltman. Weinberg & Reis Co.. L.P.A.. 323 West Lakeside Avenue. Suite #200. Cleveland. Ohio 44113-1099 (Claimant) in the amount of$2.173.70 & $450.66 against the estate of the above named decedent. This claim is filed under Section 3532 (b) (2) of the Probate, Estates and Fiduciaries Code. The said decedent, who resided at P.O. Box 560 Shippensburg. P A 17257 , died on August 28th. (Address) 2001. Written notice of this claim was given to Susan N. Sugart. Fiduciary & David Cleaver. Esquire 918 Momoe Street Oberlin PA 17113 & 1035 Wa eAve. Chamberbur PA 17201 on (Pennal representative, if any, or counsel) '2001 ~~ - ~ '~ (C aimant) \.. Traci L. Soos, Agent for the Claimant c/o Weltman, Weinberg, & Reis Co., L.P.A. 323 W. Lakeside Ave., Suite200 Cleveland. Ohio 44113 (Claimant's Address) I'D CJ' 15 ",'.:~:,', (.> ".'. Q)c!l cr: .. CERTIFICA nON OF NOTICE UNDER RULE 5.6(A) Name of Decedent: Date of Death: File No.: Michael G. Gossert August 28, 2001 21-01-0828 To the Register: I certify that Notice of Beneficial Interest 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 September 10, 2001. Susan N. Shughart 918 Monroe Street Oberlin, P A 17113 Notice has now been given to ail persons entitled thereto under Rule 5.6(A) except: (fj '.' .0 't.::c \1,) :::: Uc3 ~~.~ Counsel for Personal Representative 1035 Wayne Avenue Chambersburg, P A 17201 N o '." D~: De~iilber 18, 2001 Q RJ c..;, - c::J None 15 ",,1' - p Citicorp Credit Services, Inc. -- Citicorp Credit See/ices, "Inc. I ~ ~ ;;20-01 r\ Subsidiary of Gticorp KJn,a, City RegionJI Center 7920 N. W. 110'" St KJnsa, City ~IO 6-1153 ~d'(\ btAIW(lt1i-y ~(ihlJuse. ~~ ,~:;;;~~ " , RE: The Estate of Y'/l/'M aLf a ao~ File Number: ~ I-DI-'8;l}f Dear Sir/Madam, _Pleasejfind enclosed our claim against the above mentioned esta~e. Please returnla FILED stamped copy in the enclosed envelope. Thank you for your attention to this matter. Very Truly Yours, ~.~ Unit Manager oc ,.. -.. =c.t" ::1 ::;::;- cr .- n.. ~ :o~ en c), r;;-'.Q L :t:> 2: U1 -I::> =-- o ,- ., W N .4 c,' .. . IN THE COURT OF COHolON PLEAS, G.mbe.rL..au--d COtlNTy PENNSYLVANIA ORPHANS' COURX DI~SION ESTATE OF VYlchi C~ ~n~~C+- Deceased Register's # ~ CLAIM To the Clerk of the Orphans' Court Division: .. Index and make proper entry in your official records'of the clai~ of CmCORP CREDIT SERVICES. INe. in the amount of . ~ ~.~.nQ'. 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) (2f~4~<2o..1d .4-mi~Q.~S- The said decedent, whose last known residence was at ()C>__ ~'X 5l pn) (\ 5~r)\5hj~~")+=:n..:icO Written notice of this claim was given to ~h~.Q ~~~f) ~ J~S (f':n.l\~ Q.w /~'rnt"Y)~}(,pnborl:t~L '<-,- C 1"'). 17.\ C) C? ~~~L (Claimant) 1-" Tammy Anzelone Manager for CITICORP CREDIT SERVICES, INC. 7930 NW 110 Street, Kansas City, MO 64153 (Claimant's Address) t.n ..- :z <::::: -, :1:: :_1 ........i~ r...;. C~; (1)0: 0: p :.~J . ..0 t:s:: <1>::;;: ~3o I BT 00 Al 1 ~ PD AHEAD SITE:KC-CD m.. .' . ". .... ., . t .II!\AIlotTtmi~ 1185 VC 0001 CV 4 CHOICE VISA P.O. BOX 8101 S HACKENSACK, NJ USA 07606-8101 TM:CD-6300 ~ ACID:KCB6054 09/26/00 Mm_ ru ; ...... '.. ,RTlt, 09/20/01 21:03:26 MICHAEL G GOSSERT POBOX 560 SHIPPENSBURG 17257-0560 PA For CUltome, Se,vlce call 0' w,lte CHOICE CHOICE VISA Account Number 1-800-934-2788 BOX 6248 SIOUX FALLS, SD 57117 For billing inquiries write to this address; calling will not preserve your rights. 4428 1350 1073 3285 Payment must be received by 1:00 pm local time on 09/26/00 Statement Date Total C,edlt Line Calh Advance limit Available C,edlt Line Available Calh Line 09/01/00 $9140 $6900 $8166 $6900 AVMENT THANK YOU URCHASES*FINANCE CHARGE*PERIODIC RATE Activi Since Last Statement Amount TIC Bin#orMer# A Sic 5000- 0 0000 0 0 12 0 4 0000 0 70000000000 he careful way yoU manage your account ned the option to make no payment this If ou choose to pay, your Minimum Amount D e is $20.00. Please remember finance charges w"11 accrue as usual. Thank you. .f 91"3 . ~ 2. -12. <i0 I=c -44<".00 OIR. s 51 S .02 C!.,R BA-L J.tr s for just $4.50 each' on dining, music, videos, electronics, sions to theme parks and more' 1-800-291-0266 and mention code ECIT08 ConnectionsSM, a program by MemberWorks E d at 3AM what your CitibankCR) credit c is? Now yoU can see your balance, m nt, and check posted payments any time, d or nigh , log-on and sign up today for A count Onl"ne at www.citibankcards.com Ace nt Summa Previous + Purchases - Payments Balance & Advancel Purchases 101102 5000 Advances Total 1011 2 5000 Rate Summary PURCHASES ADVANCES Numberofdays 29 this BlUing PeriOd Balance SUbjectto 997.22 Finance Charge Periodic Rate 1.2833370 .0421970 Nominal Annual 15.40070 15.40070 Percentage Rate Annual Percentage Rate 15.40070 15.40070 Amount Due - C.ediu + Finance + Late = Balenc. Pur Min Due Cha,gel Cherge. Adv Min Due Amount OCl 2 Fees Past Due 1 2 MinAmtouePD AHEA \. INVENTORY Estate of GOSSERT MICHAEL G. , Deceased No. 21 01 0828 Date of Death 08/28/2001 Social Security No. 162425880 also known as Personal Repr-esentative(s) of the above Estate, deceased, verify that the items appearing in the fo/lowing inventory include all of the personal assets wherever situate and all of the real estate 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 Decedent owned no real estate outside 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. IM/e understand that false statements herein made are subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. Name of Attorney: David C. Cleaver 1.0. No.: 07283 Personal Representative: Address: 1035 Wayne Avenue Chambersburg Telephone: 717-264-1110 Susan N. Shughart Dated ~ d.\~ PA 17201 Description Stocks & Bonds --- ,... ::-.J ... .. Value ,-., ,....., I"') Closely-Held Corporation, Partnership or Sole-Proprietorship f f'J Mortgages & Notes Receivable , ,J \...:1 Cash, Bank Deposits, & Misc. Personal Property Allfirst Bank, Checking Account 1,363.22 Proceeds from sale of automobile and other personal property 1,414.22 Total (Attach Additional Sheets if necessary) 41,667.52 NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative, include the value of each item, but such figures should not be extended into the total of the Inventory. RW-4 , Continuation of Inventory 60SSERT MICHAEL G. 21 01 0828 PaQe 1 Description of Inventory Description Decedent's payroll checks (six checks) Value 3,095.58 Rebate from Mutual of Omaha 460.66 Refund from News Chronicle 91.48 Mutual of Omaha - insurance 3,285.97 Vacation Club 286.84 Refund from Sprint 13.38 Mutual of Omaha - insurance 571.44 Comcast - cable refund 1.68 Valley Heating & Cooling - refund 733.05 Refund - car insurance 102.00 Refund - Federal income tax 1,720.00 Refund - State income tax 28.00 Real Estate Real estate situate in Shippensburg, Cumberland Co., PA known as 13 South Queen Street, Shippensburg, PA 28,500.00 Subtotal $ 38,890.08 41,667.52 Grand Total $ \1'1-6--9 BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 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 'r'~) ,.L,_ J,-,.~ 17 DAVID C CLEAVER D C CLEAVER 8 ASSOCS 1035 WAYNE AVE CHAMBERSBURG PA IT~ol 06-10-2002 GOSSERT 08-28-2001 21 01-0828 CUMBERLAND 101 Allount Rellitted '* REY-1547 EX iFP (01-021 MICHAEl G 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:i54-j-E3f-AFP--foY:02T-No'~''-icE--oF-YNHEifi;:Ai.fci-TAx-jfpPR"irisEi..-ENT-:--AL:rOwAi.fci-ifi-------------- --- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF GOSSERT MICHAEl G FILE NO. 21 01-0828 ACN 101 DATE 06-10-2002 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) (5) (6) (7) 28,500.00 .00 .00 .00 13,167.52 .00 .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. Charitab1e/Governllenta1 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 AX CR DITS: NOTE: DATE + INTEREST/PEN PAID (-) NUMBER · IF PAID AFTER DATE INDICATED. SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. (9) (10) 10.141.39 38.404.07 NOTE: To insure proper credit to your account. subllit the upper portion of this forll with your tax paYllent. 41.667.52 (11) (12) (13) (14) 48.545 46 6.877.94- .00 6.877.94- .00 .00 .00 .00 X 00 = X 045 = X 12 = X 15 = (19)= .00 .00 .00 .00 .00 AMOUNT PAID TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE .00 .00 .00 .00 ( IF TOTAL DUE IS LESS THAN $1. NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR). YOU /'lAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) GO'( t/' STATUS REPORT UNDER RULE 6.12 Name of Decedent: Michael G. Gassert Date of Death: August 28, 2001 Admin. No.:21-01-0828 Will No.: Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above captioned estate: A. State whether administration of the estate is complete: Yes B. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: C. If the answer to No. 1 is Yes, state the following: 1. Did the personal representative file a final account with the Court? No 2. The separate Orphans' Court No. (if any) for the personal representative's account is: 3. Did the personal representative state an account informally to the parties in interest? Yes 4. 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: February 14, 2003 ~C.-~ David C. Cleaver 1035 Wayne Avenue Chambersburg, P A 17201 (717) 264-1110 Counsel for Personal Representative \ REV-l500 EX + (lHIO) . COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAl. USE 0Hl y /'1-0-- 9 FILE NUMBER 2 1 -0 1 0 8 2 8 ""C1iOOvCOir ~- - - if:iiii:R- - DECEDENT'S NAME (lAST. FIRST, At() MlOOlE INITIAL) I- Z W C W (.) W C GeSSERT MICHAEL G. DATE OF DEATH (MM-OO-V_) DATE OF BIRTH (MM-OO-V_) SOaAl SECURITY NUMBER 1 62- 4 2 - 5 8 8 0 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOaAl SECURITY NUMBER w ~ ~ :$1/1 OO::~ wfl.O :x: 00 OO::..J fl.1O fl. 4( 08/28/2001 02125/1949 (IF APPlIC\BLE) SURVIVING SPOUSE'S NAME (LAST, FIRST. AI() MOOLE INITIAL) o 3. Remainder Return (daleoldoalllpriart.12.1U2) o 5. Federal Estate Tax Return Required .Q... 8. Total Number of Safe Deposit Boxes o 11. Election 10 lax under Sec. 91 13(A) (AI!acIl Sdt 0) N/A [Xl 1. Original Return o 4. Limited Estate o 6. Decedent Died Testate (AltachtopyafWl) o 9. Litigation Proceeds Received o 2. Supplemental Return o 4a. Future Interest Compromise (dale 01 doaIIl.....12-12.Q) D 7. Decedent Maintained a Living Trust (AI!acIl copy otTrust) D 10. Spousal Pover1y Credit (dale 01 doaIIl between 12-31.91 and 1-1-95) tff$$E(trJQtilMO$t:EJlttbMPtEtEttAtt~tb~~E$PONDENCEANb:dQNROONtIAt?tAXI~~ORMAfi6fi.l:SH60tb'~Ebll'{EettbT6t: NAME COMPLETE MAILING ADDRESS David C. Cleaver 1035 Wayne Avenue FIRM NAME (If Applcabe) David C. Cleaver & Associates P.C. TELEPHONE NUMBER 717-264-1110 Chambersbur PA 17201 ~ z w o z o fl. III W 0:: a:: o o z o i= <( I- ::> a.. :!: o (.) ~ z o i= S ::> l- ii: <( (.) w a::: 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held CoIporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule 0) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) (6) D Separate Billing Requested (8) 28,5tID.1>0 OFFICIAl. USE ONLY (1) (2) (3) (4) (5) d r', : I :',j 13,167.52 7. Inter-Vivos Transfers & Miscellaneous Non..probale Property (7) (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Cosls (Schedule H) (9) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 1 1. Total Deductions (total Lines 9 & 10) 12. Net Value of Es1ate (Line 8 minus Line 11) 13. Charitable and Governmental BequestslSec 9113 Trusts for which an election to tax has not been made (Schedule J) \.T 14. Net Value Subject to Tax (Line 12 minus Line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) x .0_ (15) X .0_(16) X .12 (17) X .15 (18) (19) 41,667.52 10,141.39 38,404.07 (11) (12) (13) 48,545.46 -6,877.94 16. Amount of line 14 taxable at lineal rate (14) -6,877.94 17. Amount of Line 14 taxable at sibling rate 18. Amount of Line 14laxable at collateral rate 20. D CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT .. t<::t:;ttt:t)i.>':{BeSORE:tttANSWE:~~:AtltQUEStfbNS:ON.'.~MR$E';SibE:.ANf)'.RE:CHE:CK'~MAtH{:g:g:~tit::::~:r:~::::)t( 19. Tax Due d c I t Add Dece ent's ampl e e ress: STREET ADDRESS - 13 South Queen Street . aTY 1 STATE I ZIP Chambersburg PA 17257 Tax Payments and Credits: 1. Tax Due (page 1 Line 19) (1) 2. CreditslPayments A Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C) (2) 3. InteresllPenalty if applicable D. Interest E. Penalty T otallnteresllPenalty ( D + E ) (3) 4. If Line 2 is g-eater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Une 20 to request a refund (4) 5. If Line 1 + Line 3 is [Teater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BAlANCE DUE. (58) Make Check 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 No a. retain the use or income of the property transferred;......................................................................... 0 00 b. retain the right to designate who shall use the property transferred or its income;........ ....................... ....... 0 00 c. retain a reversionary interest;.or.... .......... ............................................ .... ....................... .,. .......... 0 00 d. receive the promise for life of either payments, benefits or care?......................................................... 0 00 2. If death occurred after December 12,1982, did decedent transfer property within one year of death without receiving adequate consideration?.......................... ....... .............................................. ..... ..... 0 00 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death:!........ ....... 0 00 4. Did decedent own an Individual Retirement Account, annuity, or other nol\ill"obate property which contains a beneficiary designati0ll2. ..... .... ...................................... ............. .......................... ........... 0 00 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. PA 17113 DATE ~-A-~ JlJA / 7~"/ 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}l. 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) O~]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-ooe 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 decedenfs 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 decedenfs siblings is 12% [72 P.S. ~9116(a)(1.3)]. A sibling is defined, under Section 9102, as an incflVidual who has at least one parent in common with the decedent, whether by blood or adoption. -_.~. COMMONWEAlTH Of PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE A REAL ESTATE EST ATE OF FILE NUMBER GaSSERT MICHAEL G. 21 01 0828 All real property owned solely or as a tenant In common must be reported at blr market value. Fair mari<el value is defined as the price al which property would be exchanged between a wiDing buyer and a w~~ng seller, neither being compelled 10 buy or sell. both having reasonable knowledge of the relevanl facts. Real property which Is jolntly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION Real estate situate in the Borough of Shippensburg, Cumberland County, PA known as 13 South Queen Street, Shippensburg, PA (See appraisal attached) VAlUE AT DATE OF DEATH 28,500.00 TOTAl... (Also enter on line " Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 28 500.00 -_..~~.. COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESDENT DECEDENT SCHEDULE E CASH. BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER 21 01 ESTATE OF GOSSERT MICHAEL G. 0828 Include the proceeds of litigation and the date !he proceeds were received by !he 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. 14. DESCRIPTION VAlUE AT DATE OF DEATH 1,363.22 Allfirst Bank, Checking Account Proceeds from sale of automobile and other personal property 1,414.22 Decedent's payroll checks (six checks) 3,095.58 Rebate from Mutual of Omaha 460.66 Refund from News Chronicle 91.48 Mutual of Omaha - insurance 3,285.97 Vacation Club 286.84 Refund from Sprint 13.38 Mutual of Omaha - insurance 571.44 Comeast - eable refund 1.68 Valley Heating & Cooling - refund 733.05 Refund - ear insurance 102.00 Refund - Federal income tax 1,720.00 Refund - State income tax 28.00 TOT AI.. (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 13167.52 _.'e."~. COMMONWEAlTH OF PENNSYlVANIA INHERITANCE TAX RETURN RESDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER ESTATE OF GOSSERT MICHAEL G. 21 01 0828 Debts of decedent must be reported on Schedule I. ITEM NUMBER A. 1. B. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. DESCRIPTION AMOUNT FUNERAL EXPENSES: Fogelsanger-Bricker Funeral Home - funeral 4,577.90 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative (5) Susan N. Shughart Social Security Number(s) I EIN Number of Personal Representative(s) Street Address 918 Monroe Street City Oberlin State PA Zip 17113 Year(s) Commission Paid: 2002 Attorney Fees David C. Cleaver Family Exemption: (If decedenfs address is not the same as claimanfs, attach explanation) Claimant Street Adltess 2,000.00 2,000.00 City Relationship of Claimant to Decedent State Zip Probate Fees Cumberland County Register of Wills 125.00 Accountanfs Fees Tax Return Prepare!'s Fees Michael McCauley - appraising real estate Sterling Property Management - winterizing decedent's house Pennsylvania Power & Light - gas GPU - electric Borough of Shippensburg - utilities Borough of Shippensburg - turn off water Gas for decedent's car Cost of new locks - decedent's residence Postage Cost of preparing automobile for sale 275.00 45.07 327.21 184.26 439.40 25.00 10.00 56.09 10.74 65.72 TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed. insert additional sheets of the same size) 10.141.39 -""..~.. COMMONWEALTH OF PENNS'VtVANlA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS FILE NUMBER 21 01 ESTATE OF GeSSERT MICHAEL G. 0828 Include unreimbursed medical expenses. ITEM NUMBER 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. DESCRIPTION AMOUNT 29,938.06 Washington Mutual Home Loans ~ balance owed on mortgage MBNA America, Account No. 5490-9943-0603-5528 514.49 Capitol One, Account No. 5291-4918-7209-1358 1,081.86 Allfirst Visa Account No. 4336-0090-8183 450.66 Choice, Account No. 4428-1350-1073-3285 515.02 Allfirst Master Charge Account No. 5393-6492-0188-1800 2,173.70 First USA Visa Account No. 4417-1127-6110-1676 905.88 AT&T Universal Card, Account No. 5398-5700-4011~5678 1,134.65 Franklin Mint, Account No. 39046497 114.48 Chambersburg Hospital - balance due at date of death 35.00 Moffitt, Heart & Vascular - balance due at date of death 200.00 Cumbertand Valley EMS - balance due at death 547.50 Sprint - telephone 22.17 Chase, Account No. 2145-11818-4 770.60 TOT AI.. (Also enter on line 10, Recapitulation) $ (If more space is needed. insert additional sheets of the same size) 38,404.07 -- _."a.~.. . COMMONWEAlTH Of PENNSYlVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF FilE NUMBER GOSSr- '....1:\ G ?1 01 0828 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE 1. TAXABLE DISTRIBUTIONS Qnclude outright spousal distributions} 1. Susan N. Shughart Sister 100% 918 Monroe Street Oberlin, PA 17113 ENTER DOLlAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17. AS APPROPRIATE, ON REV 1500 COVER SHEET II. 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 II - ENTER TOTAl NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEE $ (If more space is needed. insert additional sheets of the same size)