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Home My WebLink About09-15-06 ...d 15056041125 REV-1500 EX (06-05) PA Department of Revenue '* Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 280601 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death OFFICIAL USE ONLY County Code Year 2 1 0 6 File Number o 6 0 2 Date of Birth 203109460 o 6 1 9 2 0 0 6 o 4 0 8 1 9 2 1 S TEl G L E MAN DERWOOD MI D Decedent's Last Name Suffix Decedent's First Name (If Applicable) Enter Surviving Spouse's Infonnation Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW [&) 1. Original Return o 4. Limited Estate o 6. Decedent Died Testate (Attach Copy of Will) o 9. Litigation Proceeds Received o 2. Supplemental Return o 4a. Future Interest Compromise (date of death after 12-12-82) o 7. Decedent Maintained a Living Trust (Attach Copy of Trust) o 10. Spousal Poverty Credit (date of death 0 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number o o 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes H A R 0 L D SIR WIN I I I Firm Name (If Applicable) 717 243 609 0 I R WIN LAW 0 F F ICE REG~ER OF WILL~~E ONLY -f (- c:,.~ First line of address ,) I _ L........._... \.- 6 4 SOU T H PIT T S T R E E T Uj Second line of address - ~~.~) -'0 -., City or Post Office State ZIP Code _ -.ll _ =:-D ~-D~ TE FILED' . N I- '~ CARLISLE P A 17013 Correspondent's e-mail address:irwinlaw@earthlink.net Under penalties of pe~ury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. IGNA RE RS R E FOR F. RETURN DATE ~ 9/1 /06 NEWVILLE CARLISLE PLEASE USE ORIGINAL FORM ONLY PA 17013 Side 1 L 15056041125 15056041125 -l ~ .-J 15056042126 REV-1500 EX 4. Mortgages & Notes Receivable (Schedule D) ........................ 4. Decedent's Social Security Number 203 1 0 946 0 1 0 o 0 0 0 0 0 0 0 0 0 0 0 0 0 3 100 2 4 7 0 0 0 0 0 0 4 1 0 0 2 4 7 1 3 2 2 8 8 2 7 3 7 4 7 1 3 9 6 6 2 9 2 7 0 3 6 1 8 Decedenfs Name: DERWOOD D. STEIGLEMAN RECAPITULATION 1. Real estate (Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1. 2. Stocks and Bonds (Schedule B) .................................. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ....... 5. 6. Jointly Owned Property (Schedule F) D Separate Billing Requested . . . . . .. 6. 7. Inter-Vivos Transfers & Miscellaneous N.2DiProbate Property (Schedule G) U Separate Billing Requested. . . . . .. 7. 8. Total Gross Assets (total Lines 1-7) ........................... 8. 9. Funeral Expenses & Administrative Costs (Schedule H) . . . . . . . . . . . . . . .. 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) . . . . . . . . . . . . 10. 11. Total Deductions (total Lines 9 & 10) . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. 12. Net Value of Estate (Line 8 minus Line 11) . . . . . . . . . . . . . . . . . . . . . . . . . 12. 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) . . . . . . . . . . . . . . . . . . 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) . . . . . . . . . . . . . . . . . . 14. 2 7 0 3 6 1 8 TAX COMPUTATION - SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X O.OL 0 0 0 15. 0 0 0 16. Amount of Line 14 taxable 2 7 0 3 6 1 at lineal rate X .012- 8 16. 1 2 1 6 6 3 17. Amount of Line 14 taxable 0 0 0 at sibling rate X .12 17. 0 0 0 18. Amount of Line 14 taxable 0 0 0 at collateral rate X. 15 18. 0 0 0 19. Tax Due . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 1 2 1 6 6 3 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT D Side 2 L 15056042126 15056042126 --I REV-1500 EX Page 3 Decedent's Complete Address: File Number 0602 DECEDENT'S NAME . DERWOOD D. STEIGlEMAN STREET ADDRESS 405 POTATO ROAD CITY I STATE \ ZIP CARLISLE PA 17013 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) 1 ,216.63 60.83 Total Credits (A + B + C) (2) 60.83 3. Interest/Penalty if applicable D. Interest E. Penalty Total Interest/Penalty ( D + E ) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) 0.00 0.00 1,155.80 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5A) (5B) A. Enter the interest on the tax due. 1,155.80 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 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 non-probate property which contains a beneficiary designation? .................................................................................................. 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. 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 three (3) percent [72 P .5. ~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 zero (0) percent [72 P .5. ~9116 (a) (1.1) (ii)J. 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 zero (0) percent [72 P .5. ~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 four and one-half (4.5) percent, 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 twelve (12) percent [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. REV-1502 EX + (6-98) ..- SCHEDULE A REAL ESTATE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER DERWOOD D. STEIGLEMAN 0602 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real Drooertv which is iointly-owned with right of survivorshiD must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION FLOOD DAMAGED MOBILE HOME AND LOT AT 405 POTATO ROAD, CARLISLE, PA 17013 Value based on sale price - Buyers: Robert and Doris Blosser VALUE AT DATE OF DEATH 10,000.00 TOTAL (Also enter on line 1, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 10,000.00 REV-1503 EX + (6-98) ,.W. COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS ESTATE OF DERWOOD D. STEIGLEMAN ALE NUMBER 0602 All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER T. DESCRIPTION VALUE AT DATE OF DEATH NONE 0.00 TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 0.00 REV-1504 EX + (6-98) .... COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE C CLOSELY-HELD CORPORATION, PARTNERSHIP OR SOLE-PROPRIETORSHIP ESTATE OF DERWOOD D. STEIGLEMAN FILE NUMBER 0602 Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporation/partnership interest of the decedent, other than a sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships. ITEM NUMBER T. DESCRIPTION VALUE AT DATE OF DEATH NONE 0.00 TOTAL (Also enter on line 3, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 0.00 REV-1507 EX + (6-98) .. . , COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE D MORTGAGES & NOTES RECEIVABLE :..'1'= ESTATE OF DERWOOD D. STEIGLEMAN FilE NUMBER 0602 All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH NONE 0.00 TOTAL (Also enter on line 4, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 0.00 --"",""'--"'~~.~~-""'-"'~"""""~'"'''"''''~''''''''''''''' REV-1508 EX + (6-98) . SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH'OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF DERWOOD D. STEIGLEMAN ITEM NUMBER 1. 2. 3. 4. 5. 6. 7. 8. FILE NUMBER 0602 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. DESCRIPTION CASH ON HAND AT TIME OF DEATH VALUE AT DATE OF DEATH 1,200.00 M & T BANK Checking Account No. 807109 Value based on bank statement attached as Exhibit "A" PROGRESSIVE INSURANCE Unearned Premium Refund 24,751.85 13.00 FLOOD DAMAGED ALL TERRAIN VEHICLE Value based on letter from insurer, attached as Exhibit liB" 2,300.00 1993 CHEVROLET CAVALIER Value based on dealer estimate attached as Exhibit "C" 100.00 MISC HOUSEHOLD FURNITURE AND PERSONAL PROPERTY 2,500.00 SPRINT Refund of Utility Payment 58.62 HEALTH ADVANTAGE, INC. Refund 79.00 TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 31.002.47 Ht:V.lbU~ t:X + (tHm) * SCHEDULE F JOINTLY-OWNED PROPERTY COMMONWEALTH OF PENNSYL VAN/A INHERITANCE TAX RETURN RESIDENT DECEDENT -. ESTATEOF DERWOOD D. STEIGLEMAN FILE NUMBER 0602 If an asset was made joint within one year of the decedent's date of death, It must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. NONE B c JOINTL Y.OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY 0;. OF DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSmUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECO'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY .HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENrSINTEREST 1. A. NONE 0.00 0.00 TOTAL (Also enter on line 6, Recapitulation) $ 0.00 (If more space is needed, insert additional sheets of the same size) REV-1510 EX + (6-98) '* COMMONWEALTI-: 0F PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF DERWOOD D. STEIGLEMAN SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY FILE NUMBER 0602 This schedule must be completed and filed ~ the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY I ITEM INCLUDE THE NAME OF THE TRANSFEREE. THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECD'S I EXCLUSION TAXABLE NUMBER THE DATE OF TRANSFER. ATTACH A COPY OFTHE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPUCABLE) VALUE 1.. NONE 0.00 0.00 TOTAL (Also enter on line 7 Recapitulation) $ 0.00 (If more space is needed, insert additional sheets of the same size) REV-1511 EX + (12-99) . COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF DERWOOD D. STEIGLEMAN SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS = FILE NUMBER 0602 ITEM NUMBER A. 1. B. 1. 2. 3. 4. Debts of decedent must be reported on Schedule I. DESCRIPTION AMOUNT FUNERAL EXPENSES: HOFFMAN-ROTH FUNERAL HOME, INC. 6,881.40 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative (s) DAVID E. STEIGLEMAN 2,050.00 Social Security Number(s)/EIN Number of Personal Representative(s) Street Address 4 PEACH ORCHARD ROAD City GARDNERS State PA Zip 17324 Year(s) Commission Paid: 2006 Attomey Fees IRWIN LAW OFFICE Family Exemption: (If decedenfs address is not the same as claimanfs, attach explanation) Claimant Street Address 3,000.00 City State Zip Relationship of Claimant to Decedent Probate Fees REGISTER OF WILLS 147.00 5 . Accountanfs Fees 6. Tax Return Preparer's Fees 7. 8. 9. 10. 11. 12. 13. 14. SHIRLEY ARMOLD, TAX COLLECTOR - 2006 Real Estate taxes AEGIS SECURITY INSURANCE COMPANY - Homeowners Insurance DIAMOND AJUTO GLASS - Car Repairs SOLLENBERGERS - Obtaining New Vehicle Titles PROTHONOTARY I SHERIFF - Court Costs for Eviction Proceeding IRWIN LAW OFFICE - Attorney Fees for Eviction Proceeding REGISTER OF WILLS - File Inventory and Appraisement POSTMASTER - Postage for Certified Letters in Eviction Proceeding 330.33 65.00 50.00 74.00 91.81 500.00 30.00 9.28 TOTAL (Also enter on line 9, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 13,228.82 REV-1512 EX + (12-03) . .' ." SCHEDULE. DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF DERWOOD D. STEIG LEMAN FILE NUMBER 0602 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unrelmbursed medical expenses. ITEM NUMBER DESCRIPTION 1 . EMBARQ Utility Bill VALUE AT DATE OF DEATH 94.70 2. ADAMS ELECTRIC COOPERATIVE Utility Bill 187.61 3. FAMILY HOME MEDICAL Hospital Bed Rental 285.57 4. LANCASTER HMA PHYSICIANS MANAGEMENT CENTER Medical Bill 12.07 5. CARLISLE REGIONAL MEDICAL CENTER Medical Bill 77.21 6. NEWVILLE COMMUNITY AMBULANCE Medical Bill 80.31 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 737.47 "0'-"" ~ + ",* COMMONWEALTH Of; PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF DERWOOD D. STEIGLEMAN SCHEDULE J BENEFICIARIES RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I. TAXABLE DISTRIBUTIONS pnclude outritt spousal distributions, and transfers under Sec. 9116 (a (1.2)] 1. DA VIO E STEIGLEMAN Lineal 4 Peach Orchard Road One-Third Residue Newville PA 17241 2. JAYNEE E HUBBELL Lineal PO Box 711 One-Third Residue Altaville CA 3. DEBRA K CAMPBELL Lineal 4 Pine Street Lot 2 One-Third Residue Mt. Holly Springs PA 17065 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV.1500 COVER SHEET ._- II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART n - ENTER TOTAL NON.TAXABLE DISTRIBUTIONS ON LINE 13 OF REV.1500 COVER SHEET $ FILE NUMBER 0602 (If more space is needed, insert additional sheets of the same size) F=!MBCrBank :::)::)rr{if.,jMtwn)~~mtI))r))~ ....................................... ....................................... >}}}~:}}::~~MSi{:}}}::}>:/: ....................................... ....................................... ....................................... JUN 0 3 -JUL 0 3 , 2 0 06 1 OF 2 :::::\}:#~~#:m):\i#::~j:)::):~:j ~~@@:::j}:jr:::::@H:%::~RR_I#~M\I)\\j:\\%%%:\\:%t%t 6 0 7 1 0 9 CLASS IC CHECKING 00 5 04344M M 021 DERWOOD D STEIGLEMAN DOROTHY J STEIGLEMAN 405 POTATO RD CARLISLE PA 17013-8938 SPRING GARDEN ACCOUNT SUMMARY ::::::j:f~:~~~~;rt~::~~:::::~~:m:d:m~::~~}:::~~RW~W@f~M?H:ny:~:::::::::::::~::M~::::~:@M@:::::::t::::::::yU:::::::::::~~T4.&~~:::::m:::::::::::::::::ijr~m;y:u:::::::::::::::m=kt%\H: NO. AMOUNT NO. AMOUNT NO. AMOUNT 26,297.36 2 23,000.00 5 5,992.11 10 19,912.27 0.00 23,392.98 ACCOUNT ACTIVITY :OEP-OSitTS" itNTEREST . CHECKS.. Iii. .:OTHER" ::::::::;:::::::::::::::::::llAII:iY:::::/:::}:::::::::::::: .... .....:. ::' :......... ...... ':::=:=: :~::~~~~:):::':':iT.:f""':~: :m(:\:'~~6f::'ONS::::::::;; .::::' ::>}~clf{{{::::::{: 06-03-06 BEGINNING BALANCE 06-06-06 CHECK NUMBER 6799 06-07-06 CHECK NUMBER 6600 06-09-06 CHECK NUMBER 6601 06-14-06 SCOTTISH RE EFT 06-15-06 CINGULAR WIRELESS, LLC600-8887600 06-19-06 CHECK NUMBER 6602 -19-06 M&T ATM CASH WITHDRAWAL ON 06/19 PLAINFIELD UNI,ROUTE 641,PLAINFIELD,PA 06-19-06 DIRECTV CHECKPAYMT 000000000006803 06-20-06 BROWNAWELLS REMODELING7177764735 06-20-06 CHECK NUMBER 6605 6- 0-06 SHEETZ 00002634CARLISLE 6-21-06 M&T ATM CASH WITHDRAWAL ON 06/20 WALNUT BOTTOM SHIPPENSBURG PA US -21-06 BEVERAGE EXPRESS CARLISLE 06-22-06 M&T ATM CASH WITHDRAWAL ON 06/22 PLAINFIELD UNI,ROUTE 641,PLAINFIELD,PA 06-22-06 M&T ATM CASH WITHDRAWAL ON 06/21 WALNUT BOTTOM SHIPPENSBURG PA US 06-23-06 DEPOSIT 06-27-06 BROWNAWELLS REMODELING717-776-4735 62.49 88.07 76.00 92.93 47.80 765.55 360.00 $26,297.36 26,234.87 26,146.80 26,070.60 25,977.87 25,930.07 52.67 16,000.00 5,000.00 33.45 500.00 24,751.85 1,716.40 25.42 500.00 1,192.96 300.00 5,000.00 16,000.00 392.98 5,392.96 23,392.96 ENDING BALANCE $23,392.98 1}~:}}rIi(ttt:t::ttttr::r}I}IIit~}:t:::::tt}}}})})})))It}}}}{@~d6f:ignfjffiiiOOM~~t}{}}fffffI}:(t:tItt}ttt}{f}t{}ttttttt{t~t:t:::t:::~:r::t:t 6799 06-06-06 6802 06-19-06 62.49 765.55 6800 06-07-06 6805* 06-20-06 66.07 5,000.00 6801 06-09-06 76.00 07/25/06 TUE 08:28 FAX Progressive Cas Ins Co ~002 I i~ PROGRE.f.fIVE 5053 Rltr9t Road. SUite 101 Mp,chanlcst:JUrg, PA 17055 Telephone' 800 274-4499 FaCSimile: 7176fJ7-6111 progf.e$sIV€.com Claim Number: 043846851 Policy Holder: Derwood Steigleman Date of Loss: 9/18/04 Date of Letter: 7/25/06 Claims Representative: Joel Reeder Phone Number: 71.7-791-5104 To Whom It May Concern: This letter was written in response to a request by David Steigleman. The claim it is regarding was a tlood loss to an All-Terrain Vehicle owned by Derwood Steigleman. The vehicle was deemed a total loss. Mr. Steigleman exercised his right to retain salvage of the vehicle. Progressive Insurance determined the salvage value of the vehicle to be $2300.00- After viewing the vehicle's salvage title, Mr. Steigleman was paid for the value of his vehicle less the $2300.00 salvage value. Mr. Steigleman was then allowed to retain possession of the vehicle. Please feel free to can me with any questions or concerns. Sincerely, oel Reeder Progressive Insurance t~~.J' J-DTlJe$ CHEVROLET, INC. 3400 HARTZDALE DRIVE AT CAPITAL CITY MALL DRIVE CAMP HILL, PA 17011 NO. SURVEY AND APPRAISAL FORM -- THIS IS NOT AN ORDER NAME ~:::~:: S~c, \~'-'A<---'=::SS L{ OS \?d~~. ~ \ \\) CITY ~ ~ LL. STATE' c.... AGE PHONE NO. DATE 1- a- D( WEST SHORE SHOPPER'S GUIDE REASON FOR VISITING US: PATRIOT G '\. OLD CUSTOMER V ~C- '" L.- 0 YEAR MAKE~..I .., ~ -^-U t." MODEL ~ \,~ BODY STYLE LLJ MILEAGE q I 4 5 L-AUTO TRANS. L/ ~ P/B PIW PIS _ 6DIo~ ~ CYL.~ COLOR ~\ VL- PAINT INTERIOR GLASS OTHER TIRES L.p. R.p. L.R. R SPARE FENDERS L.p. R.F. L.R. R. DOORS ~~" \.L..t- % WHOLESALE VALUE: ~ \ C:? O. tJ U MOTOR. REAR. TRANS. APPRAISED BY FOLLOW DATE REMARKS PHYSICAL DAMAGE REPORT V~\ve.- -.-1-. ~\. \ ;=AN ~~~~j - TO NAME CHECKED IN BY