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Home My WebLink About01-0851 PETITION FOR GRANT OF LETTERS OF ADMINISTRATION Estate of MICHAEL P. SIMONDI a/so known as Deceased. Social Security No. 557-04-4125 No. To: ~J-O/-D ~ 0,1 Register of Wills for the County of Cumberland in the Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner, who is 18 years of age or older applies for letters of administration [d.b.n.; pendente lite; durante absentia; durante minoritate] on the estate of the above decedent. Decedent was domiciled at death in Cumberland County, Pennsylvania, with his last family or principal residence at 7 Meadow View Drive, Carlisle, North Middleton Township (list street, number and municipality) Decedent, then 37 years of age, died August 22, 2001, at 1-81, Exit 45, Borough of Carlisle, Cumberland County, Pennsylvania. Decedent 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: $ unestimated $ $ $ Petitioner after a proper search has ascertained that decedent left no will and was survived by the following spouse (if any) and heirs: Name Relationship Residence Deborah J. Simondi Melissa Simondi (age 10) Rudolph D. Simondi, Sr. Frances J. Simondi Rudolph D. Simondi, Jr. Spouse Daughter Father Mother Brother 7 Meadow View Drive, Carlisle, PA 17013 233 E. Autumn Ridge Road, Moore, SC 29369 47 Grove Lane, Novato, CA 94947 47 Grove Lane, Novato, CA 94947 1430 Waterford Dr., Golden Valley, MN 55422 Decedent's spouse, mother and father have renounced their right to apply for Letters of Administration. Decedent's daughter is a minor child. THEREFORE, petitioner respectfully requests the grant of letters of administration in the appropriate form to the undersigned. ( . ~___ --, .......... A Rudolph D. Simondi, Jr. 1430 Waterford Drive Golden Valley, MN 55422 (763) 520-0977 r 7 - 8- , OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA ) : SSe COUNTY OF CUMBERLAND ) The petitioner above-named swears or affirms that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner and that as personal representative of the above deced. ent, petitioner will well and trul~".:cco~ing t: law. . Sworn to or affirmed tl subscribed ~ e this " yof Rudolph D. Simondi, Jr. Df No. Estate of MICHAEL P. SIMONDI, Deceased GRANT OF LETTERS OF ADMINISTRATION AND NOW, &r J 1 , .2l121 in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that Rudolph D. Simondi, Jr. is entitled to Letters of Administration, and in accordance with such finding, Letters of Administration are hereby granted to Rudolph D. Simondi, Jr. in the estate of Michael P. Simondi. W ill Book # Page A. Denlinger, Esquire (83794) ATTORNEY (Sup. Ct. LD. No.) MARTSON DEARDORFF WILLIAMS & OITO 10 East High Street Carlisle, PA 17013 (717) 243-3341 FEES Letters of Administration $ t/D. CO Short Certificate~ $ TOTAdJf~ F:\FILES\DA TAFILE\EST A TES\I 0435-petition.letters 15.805 REV 9/86 This is to certify that the information here given is correctly copied from an original certificate of death dul~ filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filmg. WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $2.00 p 7578472 No. ~~~~~~~ AUG 2 4 2001 Date H1051~ Rev. 1191 COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS CERTIFICATE OF DEATH (Coroner) 'RINT ~ >NENT 0< INK SEX 2. Male P STATE FILE NUMBER SOCIAL SECURITY NUMBER 3. 557-04-4125 DATE OF DEIlJH (Month. Day. \'ea,) August 22, 2001 UNDER 1 D/(,/ Hours MinUIH DATE OF BIRTH (Month. Day. Yea" BIRTHPLACE (Cily and Stale or Foreign Count,.,) PlACe. OF DEAtH (Chll!tCk only one see instructions 011 other Side) HOSPITAL: Aug.lO,1964 InpalientO ~ ~ k FACILITY NAME (II nOl.nSlltution. give slreet and number) ~,ty)~ Did decad8nt live In a township? 17<5.0 :h~:~7~i~:: of MOTHER'S NAME (First, Middle. Maiden Surname) 19. Frances Giammona INFORMANT'S MAILING ADDRESS (Street CityrTown, State, ZiP COde) 7 Meadow View Drive, Carlisle, Pa 17013 PlACE OF DISPOSITION. Nam. of Cemelery. Crematory LOCATION . C~ylTown, Stale, Zop Code 0' Other Pllce Mt. Tamalpais Cemetery o Aug. 22,2001 0301 3 .5:45 A.M. 3oe. o PLAce OF INJURY. At hom.. firm. street. fa<:tory. OniCe ~hg. .tc. (Specify) Hi hwa SIGNATURE o 31b. Coroner LICENSE NUMBER DIlJE SIGNED (Monrh. Day. \'ear) o 31c. 31d. August 22, 2001 NAME AND ADDRESS OF PERSON WHO COMPLETED CAUSE OF DEATH (Item 27) Type 0' P,int Michael L. Norris, Coroner 6375 Basehore Road, Suite #1 Mechanicsburg, Pa. 17050 DATE FILED (MonIh. Day. Yaar) ~ CIT 1-81 Southbound Ie. 8cI. DECEDENT'S USUAL OCCUPATION KINO OF BUSINESSIlNDUSTRY (~v.:.,",'t.~Iil~:;"~u~r;~,~"fl Office Supply Co. . 11 ?hipping Manager llb. DECEDENT'S MAILING AODRESS ISt,eet CltylTown. Srate. Zip Code) DECEDENT'S ACTUAL RESIDENCE (See .nSlruclions on OIl'ler side) 17b, Count Cumberland 2001 21C. LICENSE NUMBER 22tfD-0 12909-L To 'he best of my knowledg.. death occurred at th. lime, date Ind place alated. (Signatu,e and Tille) 23.. TIME OF DEATH A p rx . DATE PRONOUNCED DEAD (Month. Day. Ye.,) 24. 5:45 A. M 25. August 22, 2001 27. PAAT I: Ente, 'he diWases,mjucteS- or comptM:atlonS which caused the death. 00 not enfe, I'" mode of dying, such as cardiac or respiratory arrest, shock or he3n failure list Oflty one cause on each line b. Closed Head In uries with Chest Trauma DUE TO (OR AS A CONSEOUENCE OF): Motor Vehicle Crash DUE TO (OR AS A CONSEOUENCE OF): DUE TO (OR AS A CONSEOUENCE OF): d. WERE AUTOPSY FINDINGS -.lAllLE PRIOR TO COMPl.fT1ON OF CAUSE OF DEATH? MANNER OF DEATH DATE OF INJURY (Month, Day. Year) o ~ o N.tural Homicide NoD Accident Pending Inv..ttgaliOn Yes 0 No~ Yes 0 2Ia. 21b. CERTIFIER (Check only one) 'CEATIl'YING PHYSlCIAH (Pl1YS;Cien cerlilyong cause 01_ when a_ pIlyaic1an has pronounced dealh and completed Item 23) To the best 01 my knowledge._h_rndd""totheceuse{') Indrnetl_.aatatecl. ............................................ Could not be determined Suicide 29. 'PAONOUIlCING AND CEFlTlFYING PHYSICIAN (Pl1ysician boltl p,onouncing death and certiiyino 10 cau... '" death) To the _ of my knowledge. 6e-'h occurnd at the Ume. date, and pIece, and due 10 the ceuse{l) a.... man_ .a atIIted.. . . . . . . . . . , . . . . . . . . . . 'MEDICAL EXAMINER/CORONER On 11M bH/& o".amlnatlon end/or investigation, In my opinion, death occumtd althe lime, date, and place, and due to the cau.e(.) and "'.n.... aa atatecl.. . .. . . . . .. . . . . . . . . . . . . . . . . . . .. . . .. . . . ... . .. .. . . . . . . .. . . . . .. . . . . . . . .. .. . .. . .. . .. . . , . . . . . .. . .. . . . .. 311. REGISTRAR'SSIGNATUREANONUM~~. ~~~~ bkl ~\ 101 RACE. Amef'lcan tnd'an. B'ac~, White, ete (SpecIfy) White 10. SURVIVING SPOUSE (II wtfe. gwe maiden name) Deborah Johnson 17c;[] Yea. dacedant lived in North Middleton twp crty/ooro San Rafael CA 21d. NAME AND AODRESS OF FACILITY 22CJ<<m.an Funeral Hate 255 York Rd. Carlisle, Pa 17013 LICENSE NUMBER DATE SIGNED (Month. Day. 'tear) 23b. 230. WAS CASE REFERRED TO ME~L EXAMINER/CORONER? Yes ~ No'O 2.. : ~ro.imafe PART If: aher signiHeant condi'liQns contributing 10 death, bot llnferval between not resul1ing in the Ufldeftying cause given in PART I ; onset Bnd death i TIME OF INJURY Aprx. DESCRIBE HOW INJURY OCCURRED Unbelted operator lost control, struck tractor- ailer in median INJURY AT WORK? Yea PA ~32. 3.. .~* ;}tJO\ ., "SEP-13-2001 THU 02:33 PM PENN NATIONAL INS FAX NO, 7172556360,. J p, 03 ~f-DI-ODSI PENNSYLVANIA NATIONAL MUTUAL CASUALTY INSURANCE COMPANY Harri Ibur" Pttnnsyl vani a SB306381 In the M~tter or the Estate of: Michael P. Simondi KNOW ALL MEN BY THESE PRESEN'rS. that we, fi1) R~ndolph D. Simondi, JR. -. as Administrator of lhe Estate of Michael P. Simondi and P'l1nsylvania National Mutual Casualty Insuranc~ Company, 1'1 PennsylvatliQ Corporation, or Harrisburg, Penn5ylv~nia, as Surety, are held ~I'ld firmly bound unto the_ Commonweal th Of Pennsylvaniq in the ful1 and just sum of Twentv Thousand And No/100----------------poLLARs, ($ 20,000.00) for the gayment or which. well and truly to be made, we bind ourselves, OUf heirs, exe- cutors, Qdministrators. succeSSorS end assigns, Jointly and severally, firmly by these presents. 2001 Se~led with our seals, and dated this 17thday of September, ~--. WHEREAS, --B..ndolph D. Simondir JR. ,h:ls been, or is about to be,e,ppointed Adminis tra tor of the estate or Michael P. Simondi ,byllie Orphan Court. Common Pleas Court of Cumberland County. NOW, THEREFORE, the condition of this obliga.tion is Rueh, that if tbe said Administrator shall well and huJy discharge the dutie5 or said trust according to l~w, then this obligation is void, otherwise to remain in full force and effect. ~ / . ~d1d 1!~ '~~ ~. (SEAL) PENNSYLVANIA NATIONAL MU'rUAL CASUALTY INSURANCE COMPANY By: Form 7B-168 '" "" PENNSYLVANIA NATIONAL MUTUAL CASUALTY INSURANCE COMPANY Harrisburg, Pennsylvania POWER OF ATTORNEY Know All Men By these Presents, That PENNSYLVANIA NATIONAL MUTUAL CASUALTY INSURANCE COMPANY, a corporation of the Commonwealth of Pennsylvania, does hereby make, constitute and appoint PATRICIA K. ARBEGAST, DAVID W. HOPCRAFT AND JEFFREY L. SCOTT, ALL OF CARLISLE, PENNSYLVANIA (EACH) its true and lawful Attorney(s)-in-Fact to make, execute, seal and deliver for and on its behalf as surety as its act and deed: ANY AND ALL BONDS AND UNDERTAKINGS PROVIDED THE AMOUNT OF NO ONE BOND OR UNDERTAKING EXCEEDS THE SUM OF SEVEN HUNDRED FIFTY THOUSAND DOLLARS ($750,000.00)--------------- ------------------------------------------------------------------------------------ ALL POWER AND AUTHORITY HEREBY CONFERRED SHALL HEREBY EXPIRE AND TERMINATE WITHOUT NOTICE AT MIDNIGHT OF THE 30TH DAY OF SEPTEMBER 2002, AS RESPECTS EXECUTION SUBSEQUENT THERETO. and the execution of such bonds in pursuance of these presents shall be as binding upon said Company as fully and amply, to all intents and purposes, as if they had been duly executed and acknowledged by the regularly elected officers of the Company at its office in Harrisburg Pennsylvania, in their own proper persons. This appointment is made by and under the authorization of a resolution adopted by the Board of Directors of the Company on October 24, 1973 at Harrisburg, Pennsylvania, which resolution is shown on the reverse side hereof and is now in full force and effect. In Witness Whereof: PENNSYLVANIA NATIONAL MUTUAL CASUALTY INSURANCE COMPANY has caused these presents to be signed and its corporate seal to be affixed on SEPTEMBER 20, 2000 " ;"!.::~;.~;:~~~ \{C:;:~:)l ", ~r "~'1\'~" +';; "~'~~'.>:'''I.~~ " PENNSYLVANIA NATIONAL MUTUAL CASUALTY INSURANCE COMPANY By t:4~~/tt'(?, fK:;t17 - J' Kenneth R. Shutts-Secretary Commonwealth of Pennsylvania, County of Dauphin - ss: (' ~,~~, (\. ~'\..e_t?-, Public NOTARIAL SEAL CHRISTINA ENCK, Notary Public Harrisburg, Dauphin County My Commission Expires Jan. 27, 2003 I, Thomas L. Vehar, Vice President, Surety of the PENNSYL VANIA NATIONAL MUTUAL CASUALTY INSURANCE COMPANY, a corporation of the Commonwealth of Pennsylvania, do hereby certify that the above and foregoing is a true and correct copy of a Power of Attorney, executed by the said Company, which is still in full force and effect. On SEPTEMBER 20,2000 , before me appeared Kenneth R. Shutts to me personally known, who being by me duly sworn, did say that he resides in the Commonwealth of Pennsylvania, that he is Secretary of PENNSYL VANIA NATIONAL MUTUAL CASUALTY INSURANCE COMPANY, that he is the individual described in and who executed the preceding instrument, and that the seal affixed on said instrument is the corporate seal of said Company, and that said instrument was signed and sealed on behalf of said Company by authority and direction of said Company, and the said officer acknowledged said instrument to be the free act and deed of said Company. ~....:::\~::;.itJ~...~>.,. ~::~:i,;~;~:\! Commonwealth of Pennsylvania, County of Dauphin - ss: In Witne.. Whereof, I have hereunto set my hand and affixed the corporate seal of said Company on ~ 09/17/01 . ~yl #- Vice President, Surety IMPORTANT NOTICE: This border must be RED in color. If it is not RED, this is not a certified copy. Telephone us at Area Code 717-255-6870. ~ 78-190(Rev 1/99) . · SEP-13-2001 THU 02:33 PM PENN NATIONAL INS FAX NO. 7172556360 P. 02 GENERAL AGREEMENT OF INDEMNITY In consideration of the execution by the Pennsylvania National Mutual Casualty Insurance Company (hereinafter called Company) of the bond herein applied for, I hereby agree: FIRST t to pay to the Company premiums and charges at the rates, and at the times specified in respect to said bond and will continue to pay annually until satisfactory evidence of the tcnnination of such liability shall be furnished to the Company; SECOND, to indemnify the Company against all10ss, liability) costs, damages, attorneys fees and expenses whatever, which the Company may sustain or incur by reason or in consequence of having executed said bond; THIRD, that the Company shall have the right, and is hereby authorized, but not require~ to adjust, settle or compromise any claim, demand, suit or judament upon said bond, unless I shall request the Company to litigate such claim or demand or defend such suit or to appeal from such judgment, and shall deposit with the Company collateral satisfactory to it in kind and amount; FOURTH. that the Company shall have the absolute right to procure its release from said bond under any law for the release of sureties. and the Company is hereby released of and from any damages that may be sustained by me by reason of such release; FIFTH, that a representative of the Company will be permitted at any time to examine the assets covered by the bond; SIXTH, that the above agreements shall bind me and my heirs. executors, administrators, successors and assigns, jointly and severally. Dated this 17th day of S fl p t pm h p r, ? () () 1 . 2;;;;;d ~ · ~. ~ Wi~Qe.'i$ ---r;A~ ~rrl;SdY) ~ Ptincipal --.,... ~ -. ~Ub.&.."\'" ~,S\lleo\.~cl\ 141L. F: \FILES\DA T AFILE\EST A TES\ I 043 5-renunciation ~/-O/-~5/ RENUNCIATION In Re Estate of Michael P. Simondi, deceased. To the Register of Wills of Cumberland County, Pennsylvania. The undersigned parents of the above decedent hereby renounce the right to administer the estate and respectfully asks that Letters of Administration be issued to Rudolph D. Simondi, Jr. WITNESS my hand this /ltiJ day of Sf'~ he.1( , ~()o/ . K.J~~. S'-,;...~ ~ Rudolph D. Simondi, Sr. 47 Grove Lane Novato, CA 94947 (415) 892-2594 . ~..~~.... 9'- ~ Frances J. Simondi 47 Grove Lane Novato, CA 94947 (415) 892-2594 F \FILES\DA T AFILE\EST A TES\I 0435-renunciation ~/-o/ -cf5/ RENUNCIATION In Re Estate of Michael P. Simondi, deceased. To the Register of Wills of Cumberland County, Pennsylvania. The undersigned spouse of the above decedent hereby renounces the right to administer the estate and respectfully asks that Letters of Administration be issued to Rudolph D. Simondi, Jr. WITNESS my hand this I ~a day of JdoL:ila~ , ~~IY157YL' Deborah J. SlffiO 1 7 Meadow View Drive Carlisle, P A 17013 (717) 249-8920 ,~. E F: \FILES\DA T AFILE\EST A TES\ 1043S-notice.cer CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: MICHAEL P. SIMONDI Date of Death: August 22, 2001 File No. 21-01-0851 To the Register: I certify that notice of estate administration required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on or about October 10, 2001. Deborah J. Simondi, 7 Meadow View Drive, Carlisle, PA 17013 Suzanne A. Leonard, Guardian of Melissa Simondi, 233 East Autumn Ridge Road, Moore, SC 29369-8911 Date: October 10,2001 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except: N/A t~ AJ.J.7'- Mark A. Denlinger, Esquire MARTSON DEARDORFF WILLIAMS & OTTO Ten East High Street Carlisle, P A 17013 (717) 243-3341 Attorneys for Personal Representative Signature Name F:\FILES\DA TAFILE\ESTA TES\I0435-I.account IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION NO. 21-01-0851 ESTATE OF MICHAEL P. SIMONDI, Deceased Late of North Middleton Township, Cumberland County, Pennsylvania FIRST AND FINAL ACCOUNT OF RUDOLPH D. SIMONDI, JR., ADMINISTRATOR Date of Death: Date of Letters of Administration: Complete Advertisement of Grant of Letters: The Sentinel: Cumberland Law J oumal: Account Stated as Final to: August 22, 2001 September 17, 2001 September 22, 2001 October 5,2001 June 25, 2003 SUMMARY PRINCIP AL: Receipts Net Gains on Conversions $72,240.33 296.28 72,536.61 -30.069.79 33,466.82 -2.984.47 Disbursements Distributions Principal Balance Remaining $30,482.35 INCOME: Receipts Disbursements Incolne Balance Remaining 0.00 0.00 0.00 COMBINEDBALANCEREM~G PRINCIPAL RECEIPTS Staples, Employee Stock Purchase Plan, account balance 159.6935 shares, Staples Staples, payroll, week ending 08/18/01 Staples, payroll, week ending 08/25/01 Staples, accrued vacation pay 1997 International trailer Erie Insurance, collision insurance proceeds -1- $30,482.35 $ 513.44 2,427.34 830.73 1,283.59 770.15 100.00 4,950.53 Erie Insurance, first party funeral benefits Erie Insurance, first party death benefits First USA, credit balance Central Penn Sales, refund, storage charges AAA, Travel insurance/accidental death benefit Civil Litigation Settlement TOTAL RECEIPTS OF PRINCIPAL: NET GAINS(LOSSES) ON CONVERSIONS 159.6935 shares, Staples Cost basis: Redemption: $2,427.34 $2.723.62 TOTAL GAINS ON CONVERSIONS: PRINCIPAL DISBURSEMENTS 11/01/01 12/20/01 04/30/02 Ronan Funeral Home, P A funeral expenses Keaton Mortuaries, CA funeral expenses Rudolph D. Simondi, Jr., reimbursement for: Mount Tamalpasis Cemetary, CA Travel expenses to CA for family service Inn Marin, memorial service 11/15/02 2001 PA Estate Income Tax 11/18/02 PA Inheritance Tax 11/18/02 Register of Wills, filing fee, Supplemental Inheritance tax 01/07/03 Register of Wills, additional probate fee Reserved for later disbursement: Deborah Simondi, reimbursement for estate expenses paid: AT &T Wireless Sam's Club Circuit City Stores American Express Fleet Platinum, Acct. # 5491-0000-7537-7932, 1/2 interest in balance of $8,700.64 US Treasury, Y2 balance 2001 income tax P A Dept of Revenue, Y2 balance 2001 income tax Capital Tax Collection, Michael's 2001 income tax Rudolph D. Simondi, Jr., Executor's commission MARTSON, DEARDORFF, WILLIAMS & OTTO, attorney fees MARTSON, DEARDORFF, WILLIAMS & OTTO, disbursements: Probate fee 76.00 Copies of Deeds 3.00 1,377.75 2,479.00 500.00 102.33 87.64 365.98 280.19 4,350.32 58.00 51.00 2.79 -2- 2,500.00 5,000.00 59.95 80.00 2,000.00 51.724.60 $72,240.33 $ 296.28 $ 296.28 $ 6,569.23 2,184.91 4,356.75 8.00 681.71 15.00 195.00 5,298.25 9,050.00 10,000.00 Administrators Bond Short Certificates Register of Wills, filing fee, Inheritance Tax return Advertising, The Evening Sentinel Advertising, Cumberland Law J oumal UPS services Certified mailing fee Birth Certificates Reserved for miscellaneous costs and expenses TOTAL DISBURSEMENTS: PRINCIP AL DISTRIBUTION To: Deborah J. Simondi, spouse Staples, payroll, week ending 08/18/01 Staples, payroll, week ending 08/25/01 Staples, accrued vacation pay 1997 International trailer TOTAL PARTIAL DISTRIBUTION INCOME RECEIPTS None TOTAL INCOME RECEIPTS: INCOME DISBURSEMENTS None TOTAL INCOME DISBURSEMENTS: -3- 110.00 9.00 10.00 93.83 75.00 63.54 5.57 15.00 $ 830.73 1,283.59 770.15 100.00 460.94 250.00 $39,069.79 $ 2.984.4 7 $ 2,984.47 $ 0.00 $ 0.00 $ $ 0.00 0.00 COMMONWEALTH OF PENNSYLVANIA ) : SS. COUNTY OF CUMBERLAND ) Rudolph D. Simondi, Jr., being duly sworn according to law, deposes and says: That he is the Administrator of the Estate of Michael P. Simondi, deceased; that he has fully and faithfully discharged the duties of his office; that the foregoing First and Final Account is true and correct and fully discloses all significant transactions occurring during the accounting period; that all known claims against the estate have been paid in full; that to his knowledge, there are no claims now outstanding against the Estate; and that all taxes pr~~~::?n paid. Rudolph D. Simondi, Jr. (Administrator and Accountant) Sw~ to and subscribed before me this 15 day of July, 2003. ~.~ Notary Public . USA A. EULl .. PUBlIC. MINNESOTA ., ConInissioR Expires.llft. 31. 2005 -4- IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION NO. 2001-0851 SCHEDULE OF PROPOSED DISTRIBUTION BY RUDOLPH D. SIMONDL JR., ADMINISTRATOR Rudolph D. Simondi, Jr., Administrator of the Estate of Michael P. Simondi, deceased, proposes to distribute the balance in his hands, to wit: $30,482.35, in accordance with the intestate laws of the Commonwealth of Pennsylvania, as follows: TO: Deborah J. Simondi, spouse, balance of 'lj estate residue: Cash [$13,748.94 + $2,984.47 previously distributed = $16,733.41] $13,748.94 TO: Suzanne Leonard, guardian of Melissa Simondi, daughter, (pursuant to Certificate of Appointment in the Probate Court of the State of South Carolina, County of Spartanburg, copy attached) 'lj estate residue: Cash TOTAL DISTRIBUTION: $16,733.41 $30,482.35 STATEMENT OF THE REASONS FOR THE PROPOSED DISTRIBUTION The above distribution is proposed in accordance with the Probate, Estates and Fiduciaries Code, 20 Pa. C.S.A. 992102(4) and 2103(1). ~C?~~1 Rudolph D. Simondi, Jr., Administrator Sworn to and subscribed before me this ~~~3 Notary Public - ...... &1M __ lULL .. MUC.--..rA lit. 'ull ___Jl.2005 ~' ":1'.;1:" -5- . STATEOFSO~~ COUNTY OF PROBATE CdURT . IN THE MATTER OF MELISSA SII"10NDI CASE NUMBER 2002GC4200012 CERTIFICATE OF APPOINTMENT SUZANNE LEONAt:\~. is to certify that is/are the duly qualified o PERSONAL REPRESENTATIVE ~ GUARDIAN o CONSERVATOR o TRUSTEE o in the above matter and ma\U~!~apPointment. having been exe~~d on the 07TH day of . ~. is now in full force and effect, including authorization to receive all monies, income. principal, interest & dividends of and belonging to said estate. RESTRICTIONS: NO EXPENDITURES OF FUNDS MAY BE MADE BY THE CONSERVATOR WITHOUT PRIOR COURT ORDER EXCEPT FOR THE PAYMENT OF COURT COSTS, BOND PREMIUM, AND ANY TAXES LEVIED BY ANY GOVERNMENTAL AUTHORITY. Executed this 07TH day of MARCH 1212 Do not accept a copy of this certificate without the raised seal of the Probate Court. FORM .141PC (11t1) 62-1-305.62-3-103.62-5-304.62-5-421.62-7-201 C'f..H I d IT ''A " ice of 'Nills COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF DETERMINATION AND ASSESSMENT OF PENNSYLVANIA ESTATE TAX BASED ON FEDERAL CLOSING LETTER DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN *' ./ BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. Z80601 HARRISBURG1 PA 17128-0601 REY-75' EX AFP (01-02) MARK A DENLINGER04sjEB 25 A 8 :29 MARTSON ETAL IDE HIGH ST C;eth"-, i""-~uurt CARLISLE CUlfl~eJio'il~ Co., PA 12-29-2003 SIMONDI 08-22-2001 21 01-0851 CUMBERLAND 202 MICHAEL P Allount Rellitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR FILES ~ RE-V =j3'6--Ex--AFP--{Or:.-02'j-----.-.-Niffici--oF--liETERMINAiIifti-AN-li-As-sEss-tiENY------------------------ ----- OF PENNSYLVANIA ESTATE TAX BASED ON FEDERAL CLOSING LETTER .. ESTATE OF SIMONDI MICHAEL P FILE NO.21 01-0851 ACN 202 DATE 12-29-2003 ESTATE TAX DETERMINATION 1. Credit For State Death Taxes as Verified .00 2. Pennsylvania Inheritance Tax Assessed (Excluding Discount and/or Interest) 681.72 3. Inheritance Tax Assessed by Other States or Territories of the United States (Excluding Discount and/or Interest) .00 4. Total Inheritance Tax Assessed 681.72 5. Pennsylvania Estate Tax Due .00 6. Amount of Pennsylvania Estate Tax Previously Assessed Based on Federal Estate Tax Return .00 7. Additional Pennsylvania Estate Tax Due .00 TAX CREDITS: PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 -IF PAID AFTER THIS DATE, SEE REVERSE SIDE (IF TOTAL DUE IS LESS THAN $11 NO PAYHENT IS REQUIRED FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR) 1 YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FOR" FOR INSTRUCTIONS.) /7- ~- / ~ BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF DETERMINATION AND ASSESSMENT OF PENNSYLVANIA ESTATE TAX BASED ON FEDERAL ESTATE TAX RETURN *' REV-ii83 EX AFP (01-03) MARK A DENLINGER ESQ MARTSON ETAL 10 E HIGH ST CARLISLE PA 17013 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 01-06-2003 SIMONDI 08-22-2001 21 01-0851 CUMBERLAND 201 MICHAEL P Amount Remitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment. CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR FILES ~ ---------------------------------------------------------------------------------------------------------------- REV-483 EX AFP (01-03) ** NOTICE OF DETERMINATION AND ASSESSMENT OF PENNSYLVANIA ESTATE TAX BASED ON FEDERAL ESTATE TAX RETURN *. ESTATE OF SIMONDI MICHAEL P FILE NO.21 01-0851 ACN 201 DATE 01-06-2003 ESTATE TAX DETERMINATION 1. Credit For State Death Taxes as Verified .00 2. Pennsylvania Inheritance Tax Assessed (Excluding Discount and/or Interest) 681.72 3. Inheritance Tax Assessed by Other States or Territories of the United States (Excluding Discount and/or Interest) .00 4. Total Inheritance Tax Assessed 681.72 5. Pennsylvania Estate Tax Due .00 TAX CREDITS: PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 *IF PAID AFTER THIS DATE, SEE REVERSE SIDE (IF TOTAL DUE IS LESS THAN *1, NO PAYMENT IS REQUIRED FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) / ~- R- I ~ 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 'i. MARK A DENLINGER MARTSON ETAL 10 E HIGH ST CARLISLE ESQ PA 17013 DATE ESTATE OF DATE OF DEATH F~LE NUMBER COUNTY ACN 12-30-2002 SIMONDI 08-22-2001 21 01-0851 CUMBERLAND 101 * REV-1S1i7 EX AFP (01-03) MICHAEL P Amount Remitted 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-1547 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF SIMONDI MICHAEL P FILE NO. 21 01-0851 ACN 101 DATE 12-30-2002 TAX RETURN WAS: (X) ACCEPTED AS FILED ) CHANGED RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: SUPPLEMENTAL 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. 4. 5. 6. 7. Closely Held Stock/Partnership Interest (Schedule C) Mortgages/Notes Receivable (Schedule D) Cash/Bank Deposits/Misc. Personal Property (Schedule E) JointlY Owned Property (Schedule F) Transfers (Schedule G) 8. Total Assets APPROVED DEDUCTIONS AND EXEMPTIONS: 9. 10. 11. 12. 13. 14. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) Debts/Mortgage Liabilities/Liens (Schedule I) Total Deductions Net Value of Tax Return RETURN (1) (2) (3) (4) (5) (6) (7) NO. 0 1 .00 .00 .00 .00 181,600.00 .00 .00 (8) (9) ClO) 46,430.22 111.79 (11) (12) (13) (14) Net Value of Estate Subject to Tax Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment. 181,600.00 46.Ji4? 01 135,057.99 .00 30,298.32 NOTE: If an assess.ent was issued preViously, lines 14, 15 and/or 16, 17, 18 and 19 will reflect figures that include the total of 6bh returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate 16. Amount of Line 14 taxable at Lineal/Class A rate 17. Amount of Line 14 at Sibling rate 18. Amount of Line 14 taxable at Collateral/Class B rate 19. Principal Tax Due TAX CREDITS' (15) 15,149.16 X 00 .00 (6) 15,149.16 X 045 = 681.72 un .00 X 12 .00 (8) .00 X 15 = .00 Cl9)= 681.72 PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 11-19-2002 CDOO1857 .00 681.71 11-19-2002 WRITEOFF .00 20.23 TOTAL TAX CREDIT 681.71 BALANCE OF TAX DUE .01 INTEREST AND PEN. .01 TOTAL DUE .02 * IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN *1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR). YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) , /'J-p- / ~ BUREAU OF INDIVIDUAL TAXES r~RIT~~E TAX DIVISION ~l. 280~Dl HARRISBURG1 PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEHENT1 ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSHENT OF TAX DATE ESTATE OF DATE OF DEATH FILE NUMBER 11 :)~QNTY ACN MARK A DENLINGER ESQ MARTSON ETAL 10 E HIGH ST CARLISLE '07. JUL -1 I",,' ., fA 17013 Ct 06-24-2002 SIMONDI 08-22-2001 21 01-0851 CUMBERLAND 101 *' REV-1547 EX AFP (01-021 MICHAEL P Allount Re.ittecl .00 21427.34 .00 .00 81408.39 .00 .00 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adll. Costs/Hisc. Expenses (Schedule H) 10. Debts/Hortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governllental Bequestsj Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax NOTE: (1) (2) (3) (4) (5) (6) (7) (9) (10) 261992.72 88.602.68 (11) (12) (13) (14) .00 X 00 = .00 X 045= .00 X 12 = .00 X 15 = NOTE: To insure proper credit to your accountl subllit the upper portion of this forll with your tax paYllent. (8) 101835.73 MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE1 PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REY=is4j-E3f-AFP--flff=02i--NCfficE--OF-'rtiHEifiTANCi-TA;rjrpPRjrisEiiiNT~--ALi-oWANCi-crR----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF SIMONDI MICHAEL P FILE NO. 21 01-0851 ACN 101 DATE 06-24-2002 TAX RETURN WAS: ( ) ACCEPTED AS FILED ( X) CHANGED SEE ATTACHED NOTICE 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. Hortgages/Notes Receivable (Schedule D) 5. Cash/Bank Deposits/Hisc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will reflect figures that include the total of 6bb returns assessed to date. ASSESSMENT OF TAX: 15. A.ount of Line 14 at Spousal rate (15) 16. A.ount 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 CREDITS: 11~.~9~ 40 1041759.67- .00 1041759.67- (19)= .00 .00 .00 .00 .00 . .. ......"'. ......-...... . {+J AHOUNT PAID DATE NUHBER INTEREST/PEN PAID (-) TOTAL TAX CREDIT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 · IF PAID AFTER DATE INDICATED 1 SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. IF TOTAL DUE IS LESS THAN $11 NO PAYHENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR)I YOU HAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FOR" FOR INSTRUCTIONS.) REV.'''';_... . COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG PA 17128-0601 DECEDENTS NAME INHERITANCE TAX EXPLANATION OF CHANGES REVIEWED BY Simondi, Michael P. Daniel Heck FILE NUMBER . ACN 2101-0851 101 ITEM SCHEDULE NO. E 9 EXPLANATION OF CHANGES The value of this item has been suspended from the appraisement of the return until the final value can be determined. A supplemental return must be filed when the value of the suspended item is determined. Assets reported as a result of court action must be reported at the full settlement value with the date of the final settlement. ROW Page 1 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 MARTSON DEARDORF WILLIAMS OTTO TEN EAST HIGH STREET CARLISLE, PA 17013 -------- fold ESTATE INFORMATION: SSN: 557-04-4125 FILE NUMBER: 2101-0851 DECEDENT NAME: SIMONDI MICHAEL P DATE OF PAYMENT: 11/19/2002 POSTMARK DATE: 00/00/0000 COUNTY: CUMBERLAND DATE OF DEATH: 08/22/2001 NO. CD 001857 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $681.71 I I I I I I I I TOTAL AMOUNT PAID: $681.71 REMARKS: MARTSON DEARDORFF ET AL CHECK# 9668 SEAL INITIALS: SK RECEIVED BY: REGISTER OF WILLS MARY C. LEWIS REGISTER OF WILLS e;~K REGISTER OF WILLS OF CUMBERLAND COUNTY STATUS REPORT UNDER RULE 6.12 (For Resident Decedents Dying After July 1, 1992) Name of Decedent: MICHAEL P. SIMONDI Date of Death: August 22, 2001 File No. : 2001-00851 Social Security No. : 557-04-4125 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 No x 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: First and Final Account of Administrator is scheduled for confirmation on August 26,2003, and the undersigned expects the estate to be completed shortly thereafter. 3. If the answer to No.1 is Yes, state thefollowing: a. Did the personal representative file a final account with the Court? Yes x No b. The separate Orphans' Court No. (if any) for the personal representatives account is: c. Did the personal representative state an account informally to the parties in interest? Yes No d. Copies of receipts, releases, joinders and approvals offormal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Date: August 19, 2003 Signature: ~".QCj'). 0 Name: Carl C. Risch, Esquire Address: MARTSON DEARDORFF WILLIAMS & OTTO Ten East High Street Carlisle, P A 17013 :5 t (717) 243-3341 Counsel for personal representative F:\FILES\DA T AFILE\EST A TES\ 1 0435-1.sREP REGISTER OF WILLS OF CUMBERLAND COUNTY STATUS REPORT UNDER RULE 6.12 (For Resident Decedents Dying After July 1, 1992) 0,;/ OK Name of Decedent: MICHAEL P. SIMONDI Date of Death: August 22, 2001 File No. : 2001-00851 Social Security No. : 557-04-4125 Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: Yes X No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No. 1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes x No b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes No x d. Date: , 2003 Copies of receipts, releases, joinders and approvals offormal or informal accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Co...QC{2. JL. Carl C. Risch, Esquire MARTSON DEARDORFF WILLIAMS & OTTO Ten East High Street Carlisle, PA 17013 (717) 243-3341 Counsel for personal representative Signature: Name: Address: C"-.l ("J C"_ F:\FILES\DA T AFILE\EST A TES\ I 0435-t.SREP REV. 1500 EX. (6-40) w .... 'O:<l:Ul Uii:'O: Wo..U J:OO Ull:..J 0..<0 0.. <l: *' I'J V......- REV -1500 INHERITANCE TAX RETURN RESIDENT DECEDENT OFFICIAL USE ONL Y 1'7-&1, COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 DECEDENTS NAME (LAST. FIRST. AND MIDDLE INITIAL) SIMONDI, MICHAEL P. .... z w o w U w o i 08/22/200 ~M-DD-YEAR) I ~A;~~~;I;;:(:M-DD-Y~R} fw APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST. FIRST AND MIDDLE INITIAL) : SIMONDI, DEBORAH 1. -t-------- - Ill! 1. Original Return FILE NUMBER 21 01 00851 COUNTY CODE YEAR NUMBER SOCIAL SECURITY NUMBER 557-04-4125 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WillS SOCIAL SECURITY NUMBER o 3. RemaInder Return (date of death prior to 12:r.l=82j o 4. Limited Estate o o o 2. Supplemental Return o o o 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach copy of Trust) 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) o 5. Federal Estate Tax Return Required o 8. Total Number of Safe Deposit Boxes o 11. Election to tax under Sec. 9113(A) (Attach Sch 0) A , .... Mark A. Denlinger, Esq. UlZ ~ ~ IRM NAME (If applicableY- 8 ~ Martson Deardorff Williams & Otto ELEPHONE NUMBER 717/243-3341 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation. Partnership or Sole-Proprietorship z o ~ ::> .... ii: <l: U w 0: 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) o Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) 6. Decedent Died Testate (Attach copy of Will) 9. Litigation Proceeds Received 10. Debts of Decedent, Mortgage Liabilities. & Liens (Schedule I) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 10 East High Street Carlisle, PA 17013 (1 ) None (2) 2,427.34.:' ' (3) None (4) None _.._~_.- (5) 8,408.39 (6) None (7) -0- (9) 26,992.72 -~----- (10) 88,602.68 OFFICIAL USE ONLY l,.~r; (8) 10,835.73 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116(a)(1.2) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES Copyright 2000 form software only The Lackner Group, Inc. z o 16. Amount of Line 14 taxable at lineal rate i= ~ ::> !i 17. Amount of Line 14 taxable at sibling rate o U ~ 18. Amount of Line 14 taxable at collateral rate .... 19. Tax Due CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Form REV-1500 EX (Rev. 6-00) Decedent's Complete Address: STREET ADDRESS 7 Meadow View Drive CITY Carlisle STATE PA ---~---- IZIP 17013 Tax Payments and Credits: 1. Tax Due (Page 1 line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) Total Credits (A + B + C) (2) 0.00 3. Interest/Penalty if applicable D. Interest E. Penalty TotallnterestlPenalty (D + E) 4. If Line 2 is greater than line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (3) (4) (5) (5A) (5B) 0.00 0.00 0.00 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred;............................................................................. 0 jg b. retain the right to designate who shall use the property transferred or its income;................................ 0 jg c. retain a reversionary interest; or............................................................................................................ 0 jg d. receive the promise for life of either payments, benefits or care?.......................................................... 0 jg 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration?... ....... ...................... ............ ............................................... ....... ....... ....... 0 jg 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?...... 0 jg 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation?............................................................................................................... jg 0 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. ,/ DATE 1430 Waterford Drive Golden Valley, MN 55422 ~IlP/-~2- o1~~ AOD~ESs- ADDRESS 10 East High Street Carlisle, PA 17013 For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. ~9116 (a) (1.1) (i)). For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. ~9116 (a) (1.1) (ii)). The statute does not 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-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P .S. ~9116 (a) (1.2)). The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~9116 1.2) [72 P.S. ~9116 (a) (1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. ~9116 (a) (1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. . SCHEDULE B STOCKS & BONDS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SIMONDI, MICHAEL P. I FILE NUMBER .. 21-01-00851 All property jointly-owned with right of survivorship must be disclosed on Schedule F. UNITVALU.. ~ VALUE.P,T-DATE . OF DEATH Is.20 --. .-~427~34. , I , ITEM I NUMBER I 1 159.6935 shares,Sfapfes DESCRIPTION I , I__~- TOTAL (Also enter on line 2, Recapitulation) I .._ _l. 2,427.34 . SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY I I I FILE NUMBER 21 ~_~~085~___~ _____ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT , i ESTATE OF SIMONDI, MICHAEL P. 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 DESCRIPTION VALUE AT DATE OF DEATH -5"13.44- Staples, Employee stock purchase plan, account balance 2 Staples, Employee 401(k) savings plan, $2,706.84, not taxable as decedent had no rights other than to designate beneficiary 0.00 3 Staples, Payroll for week ending 8/18/01 830.73 4 Staples, Payroll for week ending 8/25/01 1,283.59 5 Staples, accrued vacation pay 770.15 6 First USA, credit balance 59.95 7 Erie Insurance, collision insurance proceeds 4,950.53 8 Erie Insurance, first party death and funeral benefits of $7,500.00, not taxable 0.00 9 Note: Litigation is pending in this estate with settlement expected to benefit both decedent's spouse and daughter. Supplemental Return will be necessary upon determination of these benefits. TOTAL (Also enter on Line 5, Recapitulation) 8,408.39 . SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SIMONDI, MICHAEL P. FILE NUMBER 21 - 01 - 00851 - - --_._,~ -~-- This schedule must be completed and filed if the answer to any of questions 1 through 4 on page 2 is yes. - ---- I DESCRIPTION OF PROPERTY DA F DEA % OF -f .. - n --H. ITEM ! Indude the name of the transferee, their relationship to decedent and the date of transfer. \/I TE 0 TH DECO'S EXCLUSION TAXABLE VALUE NUMBER : Attach a copy oflhe deed for real estate. v ALUE OF ASSET INTEREST (IF APPLICABLE) I _un -r---I Cornerstone Federal Credit Union, IRA C.D. #5383-31; I beneficiary-spouse, Deborah Simondi, not taxable 5,909.11 0% 0.00.. 2 Cornerstone Federal Credit Union, IRA C.D. #5383-32; I beneficiary-spouse, Deborah Simondi, not taxable 5,981.35 0% 0.00 3 Cornerstone Federal Credit Union, IRA C.D. #5383-33; beneficiary-spouse, Deborah Simondi, not taxable 7,490,82! 0% 0.00 4 I [Above IRA accounts are not taxable to estate due to fact that Decedent was only 37 years of age and was not receiving benefits] __._ _____ I -------- ----- TOTAL (Also enter on line 7, Recapitulation) I . .L SCHEDULE H FUNERAL EXPENSES & ADIVINISTRATIVE COS1S I __ _ _ ____ -I FILE NUMBER --- ------- I 21 - 01 ~ 0085_1_______ . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SIMONDI, MICHAEL P. Debts of decedent must be reported on Schedule I. ITEM NUMBER -------- A. DESCRIPTION AMOUNT FUNERAL EXPENSES: Ronan Funeral Home, Carlisle, P A, funeral expenses 6,569.23 2 Keaton Mortuaries, Novato, CA, funeral expenses 2,184.91 3 Mount Tamalpais Cemetery, San Rafael, CA, opening and closing of crypt and engraving 1,377.75 4 I Airfare and lodging for spouse and family in California for memorial service and burial I 2,479.00 5 Inn Marin, Novato, CA, room for memorial service 500.00 1. ADMINISTRATIVE COSTS: Personal Representative's Commissions B. Social Security Number(s) I EIN Number of Personal Representative(s): Street Address I City Year(s) Commission paid I Attomey's Fees Martson Deardorff Williams & Otto (estimated) State Zip 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant DEBORAH 1. SIMONDI Street Address 7 Meadow View Drive City Carlisle 10,000.00 3,500.00 2. Relationship of Claimant to Decedent State P A Spouse Zip 17013 4. Probate Fees 76.00 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. I Other Administrative Costs 1 Administrator's Bond premium 110.00 2 The Sentinel, advertising Letters of Administration 3 Cumberland Law Journal, Advertising Letters of Administration 93.83 75.00 i I __ _J_~ Total of Continuation Schedule(s) 1 27.00 TOTAL (Also enter on line 9, Recapitulation) 26,992.72 . SchecIlJe H FLneraI Expenses & Actni1istJaive CosIs continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SIMONDI, MICHAEL P. I FILE NUMBER ----- ---- I 21-01-~~~~___ 9.00 Page 2 of Schedule H 4 Register of Wills, short certificates 5 6 Recorder of Deeds, xerox copies United Parcel Service, overnight delivery _________J I ~~-_.~.._- 3.00 15.00 . SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS J __ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT I FILE NUMBER 21 - 01 - 00851 ESTATE OF SIMONDI, MICHAEL P. Include unreimbursed medical expenses. ITEM NUMBER . -~ Allfirst Bank, 1/2 interest in mortgage account, balance $124,015.00 DESCRIPTION AMOUNT 62,007.50 2 Allfrrst Bank, 1/2 interest in mortgage account, balance $21,885.00 10,942.50 3 Cornerstone Federal Credit Union, 1/2 interest in loan account #5383-02-C/E, balance $20,932.44 10,466.22 4 AT&T Wireless, account payable 102.33 5 Sam's Club, account payable 87.64 6 Circuit City Stores, account payable 365.98 7 American Express, account payable 280.19 8 Fleet Platinum Account 5491 000075377932, 1/2 interest in account balance of $8,700.64 4,350.32 -~._--~- - TOTAL (Also enter on Line 10, Recapitulation) 88,602.68 REV -1500 EX + (6..00) ~ REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT ; FILE NUMBER 21 01 _ -,__gOUNT'( (:ODE Yg,\R SOCIAL SECURITY NUMBER 00851 NUMBER COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 ___. _ ,. _ I- Z W o w u w o - DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SIMONDI, MICHAEL P. DATE OF DEATH (MM-DD-YEAR) -. -- ---PlATE OF BIRTH(MM-DD-YEAR)-- OFFICIAL USE DNLY l'l--?;-I 10/ i 08/22/2001 I 08/1 0/1964 I - -.--------- ..___.___m____ i (IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL) I!! ~::!'" UO::~ w~g Og:ffi ~ SIMONDI, DEBORAH 1. D 1. Original Return D 4. Limited Estate D ~ Supplemental Return 557-04-4125 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER 6. Decedent Died Testate (Attach copy of Will) 9. Litigation Proceeds Received ~. D 4a. D 7. D Future Interest Compromise (date of death after 12-12-82) Decedent Maintained a Living Trust (Attach copy of Trust) 10. Spousal Poverty Credit (date of death between 207-44-5064 D 3. Remainder Retum (date of death pnor to 12-13-82) D 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes D 11.Election to tax under Sec. 9113(A) (Attach Sch 0) -------j 110 East High Street ----- Carlisle, PA 17013 L__ <hI- ~ffi ~o u~ - FIRM NAME (If applicable) Martson Deardorff W illiarns & Otto (1 ) None OFFICiAL USE ONLY (2) None ---.----..- --- (3) None ----- (4) None (5) 181,600.00 (6) None (7) None (8) 181,600.00 (9) 46,430.22 ---- (10) 111. 79 (11 ) 46,542.01 135,057.99 TELEPHONE NUMBER 717/243-3341 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) ~ D Separate Billing Requested ~ 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property ~ (Schedule G or L) ~ 8. Total Gross Assets (total Lines 1-7) u Ii! 9. Funeral Expenses & Administrative Costs (Schedule H) 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) (12) 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (13) (14) 135,057.99 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116(a)(1.2) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES x .00 (15) ~ ~ I- ::> <I. ~ U ~ I- 16.Amount of Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate 18. Amount of Line 14 taxable at collateral rate .. x .045 (16) 19. Tax Due x .12 (17) x .15 (18) CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. (19) Copyright 2000 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-00) Decedent's Complete Address: STREET ADDRESS 7 Meadow View Drive CITY Carlisle I STATE PA ZIP 17013 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1 ) Total Credits (A + B + C) (2) 0.00 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty (0 + E) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Line 20 to request a refund 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (3) 0.00 (4) (5) 0.00 (5A) (5B) 0.00 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred;.................................................................................. 0 0 ~: ~:::~ :h;e~~~~i~~~~:~~e~~s~~~..~.~~~~ .~~~ .~~~. :.~.~.~.~.~ .~~~~~~~~~~. .~.~ .i.~.~~~~~~:::::::::::::::::::: :::::::::::::::: ~ B d. receive the promise for life of either payments, benefits or care?............................................................. D 0 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration?......................................................... ............................................................. 0 0 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?........ 0 0 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .............. .................................................................................................. ...... 0 0 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. Under penalties of pe~ury, I declare that I have examined this netum, including accompanying schedules and statements. and to the best of my knowledge and belief, it IS true, correct and complete. Declarallon of preparer other than. the eersonal represE!.nt<llive is based on all information of which preparer has any knowledge. .. .____ G TURE OF PE l;'ONSIBLE FOR F LING RETURN ADDRESS DATE ING RETURN ADDRESS 1430 Waterford Drive uGold~lluValley,~ 55~2?__ Il- l ~ -0 '--. DATE /I tq/ClZ- DATE ADDRESS 10 East High Street Carlisle, PA 17013 .~ x~ 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. 99116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. 99116 (a) (1.1) (ii)]. The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. 99116 (a) (1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~9116 1.2) [72 P.S. ~9116 (a) (1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 99116 (a) (1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. ESTATE OF . COMMONWEALTH OF PENNSYLVANIA i INHERITANCE.T,.;x RETURN ~' RESIDENT DECEDENT --------""--~- -- SIMONDI, MICHAEL P. SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER 21-01-00851 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 I 2 3 1997 International Trailer 1994 Honda Civic, demolished DESCRIPTION Proceeds attributable to survival action of civil action filed to Cumberland County, P A, Civil Action - Law, No. 02-631. Copy of Settlement Order attached. Copy of letter representing position ofDept. of Revenue attached. TOTAL (Also enter on Line 5, Recapitulation) VALUE AT DATE OF DEATH 100.00 0.00 181,500.00 181,600.00 . SCHEDULEH FUNERAL EXPENSES & ADIVIINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SIMONDI, MICHAEL P. . FILE NUMBER 21 - 01 - 00851 Debts of decedent must be reported on Schedule I. ITEM NUMBER A. FUNERAL EXPENSES: DESCRIPTION AMOUNT B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Rudolph D. Simondi, Jr. Social Security Number(s) I EIN Number of Personal Representative(s): Street Address 1430 Waterford Drive City Golden Valley State MN Zip 55422 Year(s) Commission paid 2002 Attorney's Fees Martson Deardorff Williams & Otto (see attached) 2. 3. Family Exemption: (If decedent's address is not the same as c1aimanfs, attach explanation) Claimant DEBORAH J. SIMONDI Street Address 7 Meadow View Drive City Carlisle State P A Zip 17013 Relationship of Claimant to Decedent Spouse 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees Barry Swope, 2001 income tax returns 7. I 2 3 Other Administrative Costs DeMeo & DeMeo, attorney fees per settlement order (75625.00 x 15%) Central Penn Storage, storage of vehicle through 7/24/02 (2925 x 15%) Cumberland County Prothonotary, filing fee, Complaint (45.50 x 15%) Total of Continuation Schedule(s) TOTAL (Also enter on line 9, Recapitulation) 9,050.00 24,031.25 75.00 11,343.75 438.75 6.82 1,484.65 46,430.22 ESTATE OF SIMONDI, MICHAEL P. FILE NO. 21-01-00851 EXPLANATION OF SCHEDULE H. B. Item 2: Martson Deardorff Williams & Otto Attorney's fees directed pursuant to Settlement Order $226,875.00 15% attributable to survival action proceeds x .15 34,031.25 Less $10,000 reported on original Inheritance Tax Return -10,000.00 Balance of Martson Deardorff Williams & Otto Attorney's fees for Supplemental Inheritance Tax Return $24,031.25 FIFILESIDATAFILEIESTATESII04351-sch h-ex ESTATE OF *' Schec1IIe H FLnKaI Expenses & MninistratNe Costs cootinued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SIMONDI, MICHAEL P. 4 Dr. Craig Houston, expert reports (1350 x 15%) 5 6 7 8 9 10 11 Coroner's report (50 x 15%) PA State Police, photographs (41.55 x 15%) Henneman's Private Investigation, accident investigation report (889.48 x 15%) Register of Wills, filing fee, insolvent return Register of Wills, filing fee, supplemental return Hopcraft Insurance, renewal of administrator's bond Reserved for additional probate fee, filing fees for Releases/Settlement Agreement; accounting; and miscellaneous expenses to close estate FILE NUMBER 21 - 01 - 00851 Page 2 of Schedule H 202.50 7.50 6.23 133.42 10.00 15.00 110.00 1,000.00 SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SIMONDI, MICHAEL P. I FILE NUMBER 21 - 01 - 00851 Include unreimbursed medical expenses. ITEM NUMBER 1 DESCRIPTION AMOUNT u.s. Treasury, 1/2 balance, 2001 income tax 58.00 2 PA Dept. of Revenue, 1/2 balance, 2001 income tax 51.00 3 Capital Tax Collection Bureau, balance, decedent's 2001 income tax 2.79 TOTAL (Also enter on Line 10, Recapitulation) 111.79 SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SIMONDI, MICHAEL P. FILE NUMBER 21 - 01 - 00851 NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT Do Not L i!l;t TrustAA(S)_ AMOUNT OR SHARE OF ESTATE I. TAXABLE DISTRIBUTIONS (include outright spousal distributions) Deborah Simondi 7 Meadow View Drive Carlisle,PA 17013 Spouse 50% estate residue 2 Melissa Simondi 233 East Autumn Ridge Road Moore, SC 29369 i Daughter 50% estate residue Enter dollar amounts for distributions shown above on lines 15 through 17, as appropriate, on Rev 1500 cover sheet! I II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET F: IFlll!SIDA T AFILE\Oendoc.clll\ 10435-onI.lIcny Created: 0910510211:38:44 AM Revised: 091161020930:39 AM 10435.2 RUDY SIMONDI, Administrator of the Estate of Michael P. Simondi, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA v. RANnT SINGH, SAINI A VT AR, L. KEE & COMPANY, INC., OLEXION RUBBISH: HAULING, INC., andREHMAT TRUCKING, INC., NO. 02-631 CIVIL ACTION-LAW Defendants JURY TRIAL OF TWELVE DEMANDED ORDER AND NOW, this Jb~ day of September 2002, upon consideration of Plaintiff s Petition for Approval of Minor's Compromise Settlement and the concurrences attached thereto, it is hereby ordered and decreed that the Plaintiff is authorized to enter into a settlement in the amount of $1,210,000.00 (this amount includes the cost of the annuities). It is further ordered that of the total proceeds, 85% or $1,028,500.00 is attributable to the Wrongful Death Action and 15% or $181,500.00 is attributable to the Survival Action. The settlement proceeds shall be distributed as follows: Attorneys' Fees: Martson Deardorff Williams & Otto DeMeo & DeMeo $302,500.00 $226,875.00 $ 75,625.00 Attorneys' Costs: $ 5,775.40 The balance of the settlement is apportioned as follows: 1. To purchase annuities for the benefit ofthe surviving spouse, Deborah Simondi as follows: A. Plan #33 (GE Capital) Monthly Benefits Increasing for Life: $ 837/month, increasing 3.00% compounding on an annual basis for Life with 20 years guaranteed. First payment is 01/0212003 (age 47). Last guaranteed payment is 12/02/2022 (age 67). This is 240 guaranteed monthly payments, and then payments continue monthly, FOR LIFE THEREAFTER. Present Value: $212,500.00 sew. J-( r~ 13 -2. Q.. '7 ft) S-CH.c/X~3 (,/3) B. Plan #33 (First Colony) Monthly Benefits Increasing for Life: $856/ month, increasing 3.00% compounding on an annual basis for Life with 20 years guaranteed. First payment is 01/02/2003 (age 47). Last guaranteed payment is 12/02/2022 (age 67). This is 240 guaranteed monthly payments, and then payments continue monthly, FOR LIFE THEREAFTER. Present Value: $212,500.00 Total Cash Value: $425,000.00 2. To purchase annuities for the benefit ofthe surviving daughter, not the issue ofthe surviving spouse, Melissa Simondi (Date of Birth: May 27, 1991) as set forth in the Petition and as more specifically set forth as follows: A. Plan #EE (First Colony) Semiannual Benefits: $5,000 semiannually. First payment is OS/27/2009 (age 18). Last payment is 11/27/2015. This is 14 guaranteed semiannual payments, and then payments stop. Monthly Benefits for Life: $1,743/ month, payable for life guaranteed for 30 years. First payment is OS/27/2016 (age 25). Last guaranteed payment is 04/27/2046 (age 55). This is 360 guaranteed montWy payments, and then payments continue monthly, FOR LIFE THEREAFTER. Present Value: $212,500.00 B. Plan #EE (Transamerica) Semiannual Benefits: $5,000 semiannually. First payment is OS/27/2009 (age 18). Last payment is 11/27/2015. This is 14 guaranteed semiannual payments, and then payments stop. Monthly Benefits for Life: $1,780/ month, payable for life guaranteed for 30 years. First payment is OS/27/2016 (age 25). Last guaranteed payment is 04/27/2046 (age 55). This is 360 guaranteed monthly payments, and then payments continue monthly, FOR LIFE THEREAFTER. Present Value: Total Cash Value: $212,500.00 $425,000.00 3. The Estate of Michael Simondi $ 51,724.60 4. The administrator of the Estate shall comply with 20 Pa.C.S. ~ 3323(b)(3). SC ,- --J_ J H- t: ~rr-n).:) > ( 2_1 s ) 5. The administrator of the Estate is also hereby authorized to execute any general releases necessary for the payment of the settlement funds. BY THE COURT: ~<;( ~t/~ p-s J. 1 Pi H;:'~ "''!.'~....-",-: ~-~,.\.~ ~~ ';~:t C."ll;ir~:.~f:J{~. In Tty~k~" a 0\1 ; .;;, ..0J; . -c.J l~ f?\!" It. '::,~,; ,"i ..,_:~- '7A-?~ "":":~~',~--~-~~',L~~, W .. '7-'~ ~~. P;';~il'fi'."(nLi~Y S'C 1-1. C r ~.5 (5,. J::> ? ~ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPARTMENT 280601 HARRISBURG, PA 17128-0601 Telephone 8/6/2002 717-783-0972 George B Faller, Jr., Esquire Martson etal Ten East High Street Carlisle, Pa 17013 Re: Estate of Michael Simondi File Number: 2101-0851 Court Number: Cumberland-CCP-Civil-02-631 Dear Mr. Faller: The Department of Revenue has received the Petition for Approval of Settlement Claim to be filed on behalf of the above-referenced Estate in regard to a wrongful death and survival action. It has been forwarded to this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to settle the actions. Pursuant to the Petition, the 45 year-old decedent died as a result of a motor vehicle accident. Decedent is survived by the decedent's spouse and a minor child from a prior marriage. Please be advised that, based upon these facts and for inheritance tax purposes only, this Department has no objection to the proposed allocation of the gross proceeds of this action, $ 1,028,500.00 to the wrongful death claim and $ 181,500.00 to the survival claim. Proceeds of a survival action are an asset included in the decedent's estate and are subject to the imposition of Pennsylvania inheritance tax. 42 Pa.C.S.A. ~8302; 72 P.S. ~~9106, 9107. Costs and fees must be deducted in the same percentages as the proceeds are allocated. In re Estate of Merryman, 669 A.2d 1059 (Pa. Cmwlth. 1995). I trust that this letter is a sufficient representation of the Department's position on this matter. As the Department has no objections to the Petition, an attorney from the Department of Revenue will not be attending any hearing regarding it. Please contact me if you or the Court has any questions or requires anything additional from this Bureau. Finally, the approval of this allocation is limited to this estate and does not reflect the position that the Department may take in any other proposed distribution of proceeds of a wrongful death / survival action. 'nfJ~ ~ Pa~~ Inheritance Tax Division Bureau of Individual Taxes cc: Cumberland County Clerk of Courts Sc /-t . E T~( -3 ~ BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION IIEPT. '80601 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 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=[S4-j-E3f-AFP-foY':02Y-NCfficE--OF-YNHErfiTAtfCE-YAX-A-PPRXisE'MENT~--Ai:.rowAircE-oR------------ -- --- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF SIMONDI MICHAEL P FILE NO. 21 01-0851 ACN 101 DATE 06-24-2002 TAX RETURN WAS: ) ACCEPTED AS FILED ( X) CHANGED SEE ATTACHED NOTICE 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 MARK A DENLINGER MARTSON ETAL 10 E HIGH ST CARLISLE l ~";'; V,\ // -;,::,;" ESQ ~ i " ~,l PA 17013 (1) (2) (3) (4) (5) (6) (7) 06-24-2002 SIMONDI 08-22-2001 21 01-0851 CUMBERLAND 101 Amount Re.1i tted .00 2,427.34 .00 .00 8,408.39 .00 .00 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax (9) (10) 26,992.72 88.602.68 REV-15~7 EX AFP (01-02) MICHAEL P NOTE: To insure proper credit to your account, submit the upper portion of this form with your tax payment. (8) 10,835.73 (11) (12) (13) (14) 115.595 40 104,759.67- .00 104,759.67- NOTE: I~ an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will re~lect ~igures that include the total o~ ALL returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate (15) 16. Amount of Line 14 taxable at Lineal/Class A rate (16) 17. Amount of Line 14 at Sibling rate (17) 18. Amount of Line 14 taxable at Collateral/Class B rate (18) 19. Principal Tax Due TAX CREDITS: + INTEREST/PEN PAID (-) DATE NUMBER .00 X 00 = .00 .00 X 045 = .00 .00 X 12 = .00 .00 X 15 = .00 (19)= .00 AMOUNT PAID TOTAL TAX CREDIT BALANCE OF TAX DUE INTEREST AND PEN. TOTAL DUE · IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. .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 MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG PA 17128-0601 DECEDENTS NAME . REV.1470 EX (6-88) REVIEWED BY ITEM SCHEDULE NO. E 9 INHERITANCE TAX EXPLANATION OF CHANGES .-- .":-~, ~,,~ I" '1", , : . ., Simondi, Michael P. FILE NUMBER Daniel Heck ACN 2101-0851 101 EXPLANATION OF CHANGES The value of this item has been suspended from the appraisement of the return until the final value can be determined. A supplemental return must be filed when the value of the suspended item is determined. Assets reported asa result of court action must be reported at the full settlement value with the date of the final settlement. ORIGINAL Page 1